Inaccurate MDS Coding for Terminal Prognosis and Cognitive Status
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, resulting in deficiencies related to assessment accuracy. For one resident with an anoxic brain injury and blood clots, who was readmitted and placed on hospice care, the significant change MDS did not reflect the resident's terminal prognosis of six months or less, despite the presence of a physician-signed Certification of Terminal Illness and an active hospice order. The MDS Director stated that the hospice documentation was not reviewed because it was not uploaded to the electronic medical record until after the assessment was completed, and was unaware that hospice care required a terminal diagnosis of six months or less. For another resident with a history of senile degeneration of the brain and cognitive communication deficit, the quarterly MDS was inaccurately coded as "Rarely or Never Understood" and omitted required cognitive assessment scores, despite previous and subsequent assessments indicating moderate to intact cognition. The MDS Director acknowledged the error, stating the resident was cognitively intact at the time and that the information was not verified before submission. The facility did not have a specific MDS accuracy policy in place, relying solely on the RAI manual.