Inaccurate MDS Coding for Feeding Tube Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded regarding the use of a feeding tube for one resident. The resident, who had a history of malignant neoplasm of the tongue, oral mucosa hyperplasia, malnutrition, dysphagia, and a gastrostomy, was admitted with a feeding tube. However, the resident's enteral feeding order was discontinued, and the feeding tube was removed several months prior to the quarterly MDS assessment. Despite this, the MDS assessment indicated that the resident was still receiving nutrition via a feeding tube, which was inconsistent with the resident's current care and medical records. Interviews with the resident, nursing staff, the MDS Coordinator, the Registered Dietician, and the Director of Nursing confirmed that the resident no longer had a feeding tube and was receiving nutrition orally. The facility's policy required that MDS assessments be completed by qualified staff and that the information accurately reflect the resident's current status as documented in the medical record and care plans. The inaccurate coding on the MDS was verified by multiple staff members and was acknowledged as an error during the survey.