Inaccurate MDS Coding of Continence Status
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's continence status. Specifically, the MDS for one resident was incorrectly coded to indicate incontinence, despite multiple sources confirming the resident was continent. The resident's admission record listed several diagnoses, including diabetes mellitus, myocardial infarction, a broken left arm, and hypertension. Interdisciplinary team meeting notes and the MDS itself documented that the resident was able to make decisions and communicate needs. Interviews with both a CNA and an LVN confirmed the resident was not incontinent and did not require assistance with toileting, instead using a urinal independently. Further interviews revealed that the MDS nurse, responsible for completing the MDS assessments, had relied on information from the initial care plan meeting and family input. However, during a joint interview with the resident and the MDS nurse, the resident stated he was not incontinent and only used diapers at night due to delayed assistance, not due to actual incontinence. The facility's policy required staff to assess and document continence status accurately, referencing MDS criteria. The inaccurate coding on the MDS was identified as a discrepancy that could affect the resident's care.