Inaccurate MDS Coding for Hospice and Discharge Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status and services received by three residents. For two residents with significant medical conditions, including malignant neoplasm of the prostate, depression, senile degeneration of the brain, and coagulation factor deficiency, the MDS assessments did not indicate that they were receiving hospice services, despite physician orders and clinical records confirming hospice care during the required fourteen-day look-back period. The Registered Nurse Assessment Coordinator (RNAC) confirmed that the hospice status was not properly coded on the MDS for these residents. Additionally, another resident with diagnoses including aspiration pneumonia and benign prostatic hyperplasia was transferred to the emergency room, but the Discharge Return Anticipated MDS was inaccurately coded as discharge to home/community instead of to a short-term general hospital. The RNAC acknowledged this coding error during an interview. These inaccuracies were identified through review of clinical records, MDS documentation, and staff interviews.