Inaccurate Diagnosis Recorded on MDS Assessment
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that an accurate diagnosis was recorded on the Minimum Data Set (MDS) assessment for one of two sampled residents. During an interview and record review with the MDS Coordinator, it was found that the MDS 3.0 Section I - Active Diagnoses incorrectly indicated that the resident had benign prostatic hyperplasia (BPH), despite the resident not having this diagnosis. The MDS Coordinator acknowledged that this section was incorrectly coded. Review of the facility's MDS manual confirmed that the MDS assessment is intended to provide an updated and accurate picture of the resident's current health status, and the incorrect coding resulted in the facility reporting inaccurate data to CMS.