Inaccurate MDS Coding for Resident with Hearing Loss
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for a resident with hearing loss was accurately coded. The resident was admitted with a diagnosis of right ear hearing loss and used a hearing aid in the left ear. Multiple records, including the inventory sheet and social service summary, documented the presence and use of a left hearing aid and noted moderate hearing difficulty. However, the MDS assessment incorrectly indicated that the resident was not using a hearing aid and had adequate hearing ability. During interviews, both the MDS Nurse and the Director of Nursing acknowledged that the MDS assessment did not accurately reflect the resident's actual hearing status and should have been coded as moderately impaired with hearing. The facility's policy and the Resident Assessment Instrument (RAI) manual require that assessments accurately reflect the resident's status, which was not followed in this instance.