Inaccurate MDS Coding for Discharge Location and Feeding Tube Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in key areas. For one resident, the Discharge Planner documented in the discharge planning note and nursing progress note that the resident was discharged to another skilled nursing facility. However, the MDS assessment was incorrectly coded as a discharge to a short-term general hospital. The Discharge Planner acknowledged the error during an interview, stating that the correct discharge location should have been selected. Additionally, the MDS Nurse reported that she did not review sections of the assessment completed by other departments for accuracy, and the Administrator confirmed that the Discharge Planner was responsible for ensuring the assessment's correctness. For another resident with diagnoses including severe protein-calorie malnutrition, adult failure to thrive, and gastrostomy status, the physician ordered continuous tube feeding via gastrostomy tube. Despite this, the resident's annual MDS did not indicate that nutrition and hydration were provided through a feeding tube. A subsequent MDS Reconciliation Note confirmed that the resident did not eat or drink by mouth and was fed exclusively by tube feeding, highlighting the inaccuracy in the MDS coding.