Inaccurate MDS Assessment for Active Diagnosis
Penalty
Summary
The facility failed to accurately assess and submit data for one resident when the Minimum Data Set (MDS) did not reflect the resident's current status. Specifically, the MDS 3.0 Section I- Active Diagnoses for this resident indicated an active diagnosis of viral hepatitis, despite the resident not receiving any treatment for this condition at the time of assessment. Review of the resident's order summary confirmed there was no treatment for viral hepatitis, and both the MDS Coordinator and MDS Registered Nurse acknowledged that the MDS should not have indicated an active diagnosis, as per the Resident Assessment Instrument (RAI) guidelines, which require active treatment within the past 7 days for such coding. The inaccurate MDS data was transmitted to CMS, resulting in a deficiency related to assessment accuracy.