Failure to Accurately Code Admission Diagnoses on MDS Assessment
Penalty
Fine: $66,560
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to accurately identify and code a resident's diagnoses on the Minimum Data Set (MDS) assessment upon admission. Record review showed that a resident was admitted with multiple significant medical conditions, including end stage renal disease, dependence on renal dialysis, Type 2 diabetes with neuropathy, atherosclerotic heart disease, chronic ischemic heart disease, hypertension, cardiac pacemaker, cirrhosis of the liver, heart failure, atrial fibrillation, osteoarthritis, and pneumonia. However, these diagnoses were not properly coded on the resident's admission comprehensive MDS assessment. During an interview, the MDS Coordinator confirmed that the admission diagnoses were not coded correctly.