Failure to Accurately Code Dialysis in MDS Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of two residents who were receiving dialysis. For both residents, medical records and care plans documented diagnoses of end stage renal disease and dependence on renal dialysis. However, review of their MDS assessments showed that dialysis was not coded in section O, which is designated for special treatments, procedures, and programs. Interviews with the MDS nurse confirmed that dialysis was omitted from the MDS coding for both residents. The residents involved had significant medical histories, including conditions such as cerebral infarction, muscle weakness, diabetes, malnutrition, hypertension, anemia, peripheral vascular disease, chronic kidney disease, and end stage renal disease. Despite these documented needs and the presence of care plans addressing dialysis, the MDS assessments did not reflect the dialysis treatment. Facility policy and CMS guidelines require that special treatments and procedures be accurately documented in the comprehensive assessment, including the MDS.