Inaccurate MDS Coding for Resident Weight Loss
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for a resident was accurately coded to reflect a significant weight loss. The resident, who had diagnoses including unspecified protein-calorie malnutrition, dysphagia, and pneumonitis due to inhalation, experienced a weight loss of 7.2 pounds, equating to a 5.9 percent decrease over 14 days. This weight loss was documented in the resident's nutrition assessment and care plan. However, the MDS assessment incorrectly indicated that there was no weight loss in the last one to six months. The MDS coordinator, responsible for completing the assessment, misinterpreted the calculation method after consulting with the facility's MDS consultant, leading to the inaccurate entry. The Director of Nursing confirmed that the MDS was coded incorrectly. The facility's policy requires that any healthcare professional completing the MDS must certify the accuracy of the assessment, but this was not adhered to in this instance, resulting in incorrect data being transmitted to CMS.