Failure to Accurately Code Significant Weight Loss in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded to reflect significant weight loss for two residents. For one resident with dysphagia, weight records showed a loss of 8.73% over a short period, but the quarterly MDS assessment did not document this significant weight loss. The resident's care plan noted a risk for weight loss but did not address the actual significant loss that had occurred. During observation, the resident expressed concerns about being skinny, further indicating awareness of her weight change. For another resident with Parkinson's disease and other brain disorders, weight records indicated a 13.54% loss in one month, but the quarterly MDS assessment failed to code this significant weight loss. Progress notes showed interventions such as appetite stimulation and dietician involvement, and the care plan was revised to note significant weight loss at a later date. Staff interviews confirmed that the MDS assessments for both residents did not reflect the significant weight loss, and the DON acknowledged that the MDS should have included this information.