Inaccurate MDS Coding for Corrective Lenses Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident regarding the use of corrective lenses during the observation period. The resident, who had a history of hypertensive chronic kidney disease, essential primary hypertension, and falls, was documented in optometry evaluations as having cataracts and requiring eyeglasses with a specific prescription. Despite this, the MDS assessment indicated that the resident did not use corrective lenses, and that the resident had adequate vision. Interviews and observations confirmed that the resident used eyeglasses, with the resident stating they wore glasses and had been advised by an eye doctor about the need for cataract surgery. The surveyor observed the resident's eyeglasses on the bedside table, and the MDS nurse acknowledged that the assessment was coded in error, attributing the mistake to a float staff member who completed the assessment. The nurse confirmed that the resident could not see without their glasses and that the MDS should have reflected the use of corrective lenses.