Inaccurate MDS Coding for Resident Conditions and Care
Penalty
Summary
The facility failed to conduct accurate assessments for two residents by not assigning the correct codes on the Minimum Data Set (MDS) that corresponded to their current care needs. For one resident with a history of cerebrovascular disease, diabetes with neuropathy, peripheral vascular disease, hypertension, Alzheimer's disease, and gastrointestinal hemorrhage, the MDS dated 4/25/25 incorrectly documented the absence of a diabetic foot ulcer, despite a physician's note from 5/14/25 confirming the ongoing presence of a diabetic wound on the right lateral heel. The MDS Coordinator acknowledged that the diabetic foot ulcer was miscoded and that the earlier quarterly assessment had the correct information. Another resident, admitted with nontraumatic intracerebral hemorrhage and a medical history including diabetes mellitus type 2, protein calorie malnutrition, seizures, hypertension, and aphasia, was dependent for all activities of daily living. The annual MDS skin assessment indicated the presence of a stage 3 pressure ulcer/injury, but the section regarding pressure ulcer/injury care was incorrectly marked as "No," even though records confirmed the resident was receiving such care. The MDS Coordinator confirmed the miscoding, stating the section should have indicated that pressure ulcer care was being provided.