Failure to Accurately Code MDS for Active PVD Diagnosis
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident who had an active diagnosis of peripheral vascular disease (PVD). The resident, who was admitted with multiple diagnoses including diabetes mellitus, dementia, contractures, protein malnutrition, and hemiplegia, was given a new diagnosis of PVD by a podiatrist following a clinical assessment that identified classic signs and symptoms of the disease. Despite this, the quarterly MDS assessment did not reflect the new diagnosis of PVD. Interviews with facility staff revealed that the process for updating diagnoses involved the Social Service Coordinator receiving and distributing consultation notes, which were then uploaded into the electronic health record. However, the MDS nurses were unaware of the new PVD diagnosis and did not code it on the resident's MDS, stating that they review medical records and consultations for new information. The MDS nurses believed that not coding the diagnosis was accurate, despite the documented evidence and clinical findings supporting the presence of PVD.