Failure to Accurately Code Dialysis on MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's quarterly Minimum Data Set (MDS) assessment accurately reflected the receipt of dialysis treatment. The resident, who had diagnoses including dependence on renal dialysis and chronic kidney disease, was readmitted to the facility and had physician orders for renal dialysis three times per week. Despite this, the quarterly MDS assessment with an Assessment Reference Date (ARD) of 01/28/2025 was not coded to indicate that the resident received dialysis. During an interview, the Regional MDS Coordinator confirmed that the resident was receiving dialysis at the time and acknowledged that the omission was an oversight during the completion of the assessment. The failure to accurately document the dialysis treatment on the MDS assessment was identified through observations, interviews, and record review.