Inaccurate MDS Assessment for Nutritional Approaches
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident regarding nutritional approaches. The resident, who had a history of diffuse large B-cell lymphoma, muscle wasting, chronic kidney disease, and other conditions, was admitted for care and later readmitted with generalized weakness and edema. The admission MDS assessment inaccurately documented that the resident received parenteral or intravenous (IV) feeding and a mechanically altered diet, including specific entries for percent intake by artificial route and average fluid intake by IV or tube feeding. However, review of the resident's medical record and diet orders confirmed that at no time was the resident on parenteral, IV feeding, or a mechanically altered diet; the resident was consistently on a regular diet with regular texture and thin liquids, with a fluid restriction and fortified food as ordered. Interviews with facility staff, including the Dietitian, Certified Dietary Manager (CDM), and MDS Coordinator, confirmed the inaccuracies in the MDS assessment. The CDM acknowledged miscoding the resident as requiring a mechanically altered diet, and the MDS Coordinator was unable to explain the basis for the entries regarding parenteral or IV feeding. The facility's policy and job descriptions require accurate and comprehensive MDS assessments, but these were not followed in this instance, resulting in inaccurate documentation of the resident's nutritional status and care approaches.