Failure to Accurately Code Hospice Status on MDS Assessments
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments in the area of hospice care for two residents. For the first resident, who had diagnoses including senile degeneration of the brain, chronic diastolic heart failure, and chronic respiratory failure with hypoxia, the care plan and physician orders indicated she was receiving hospice services. However, her quarterly MDS did not reflect her hospice status. Interviews with the MDS Nurse, Director of Nursing (DON), and Administrator confirmed that this was an oversight and that the MDS should have indicated hospice care. Similarly, the second resident, diagnosed with dementia and hypertensive heart disease, was also receiving hospice services as documented in her care plan and physician orders. Despite this, her quarterly MDS did not indicate she was on hospice care. Staff interviews again confirmed that this was an oversight and that the MDS should have been coded to reflect the resident's hospice status.