Inaccurate MDS Assessment Coding for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's clinical status. Specifically, for one resident with a diagnosis of cerebrovascular disease and moderately impaired cognition, the comprehensive MDS assessment did not indicate the presence of an indwelling urinary catheter, despite multiple sources confirming its use. The resident's face sheet, care plan, and physician's order summary all documented the presence of a urinary catheter, and direct observation confirmed the resident had a Foley catheter in place. Interviews with facility staff revealed that the MDS nurse was responsible for the accuracy of MDS assessments, and the Director of Nursing confirmed that the care plan accurately reflected the resident's needs, but the MDS was not coded correctly. The inaccurate coding of the MDS assessment was not identified prior to the survey, and the facility's policy requires comprehensive and accurate assessments according to federal regulations.