Inaccurate MDS Coding for Catheter Use and Medication
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents. For one resident with diagnoses including dementia, hypertension, anxiety, and high cholesterol, the MDS did not reflect the presence of a suprapubic catheter, despite medical orders and care plans indicating its use and the need for related care. Documentation showed ongoing orders for catheter management and care plans addressing toileting assistance and fall risk related to the catheter tubing, but this was not captured in the MDS coding. For another resident with multiple sclerosis, depression, and weakness, the MDS was incorrectly coded to indicate the use of an anticoagulant medication, although there was no prescription for such medication. The error was attributed to the MDS coordinator inadvertently coding the wrong medication type. These inaccuracies were identified through record reviews, observations, and interviews during the survey.