Inaccurate MDS Coding for Weight Gain and Tobacco Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents. For one resident with mild cognitive impairment and psychotic disorder, a significant weight gain of over 22% in one month was documented in the medical record, but this change was not coded in section K of the quarterly MDS assessment. The Registered Dietitian acknowledged during interview that the significant weight gain should have been coded on the MDS. For another resident with a diagnosis of nicotine dependence, the use of tobacco was not coded in section J of the admission MDS assessment, despite the resident being observed smoking outside with a smoking apron and having a care plan indicating supervised smoking. The MDS Nurse confirmed during interview that the resident's tobacco use should have been coded in the MDS.