Failure to Accurately Code MDS for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident who had an indwelling urinary catheter in place since admission. Observations on two separate occasions confirmed the presence of the catheter, and clinical records, including physician orders and care plans, documented its use for obstructive uropathy. Despite this, the MDS assessment did not indicate the presence of an indwelling urinary catheter, as the relevant section was marked 'None of the above.' Interviews with staff, including the MDS Coordinator, confirmed that the omission was an error and that the catheter should have been coded in the MDS. The facility's policy requires that all resident assessments accurately reflect the resident's status at the time of assessment, but this was not followed in this instance. The deficiency was identified through observations, record reviews, and staff interviews.