Inaccurate MDS Coding for Special Treatments and Prognosis
Penalty
Summary
Facility staff failed to accurately code the Minimum Data Set (MDS) assessments for three residents, resulting in inaccurate documentation of their care needs and treatments. One resident, who was alert and oriented, reported not having received dialysis in over two years and had a new kidney, yet her MDS indicated she was receiving dialysis at the facility. Review of her physician orders confirmed there were no orders for dialysis treatment. Another resident, admitted with anemia, dementia, adult failure to thrive, and malnutrition, was on hospice care with documentation supporting a prognosis of less than six months. However, the MDS was coded to indicate the resident did not have a terminal prognosis, despite the presence of appropriate documentation in the medical record prior to MDS completion. A third resident's MDS was coded to reflect ongoing hospice care, even though the resident had been removed from hospice and had a payor source change. Social service notes confirmed the last hospice coverage date, and staff interviews revealed that the MDS should have been updated to reflect the change in hospice status. The failure to accurately code the MDS assessments was confirmed through record review and staff interviews, affecting the accuracy of resident assessments and care planning.