Failure to Accurately Code Corrective Lens Use on MDS Assessment
Penalty
Summary
The facility failed to accurately code a Minimum Data Set (MDS) assessment for one resident, resulting in an omission regarding the use of corrective lenses. Record review showed that the resident was admitted with multiple diagnoses, including chronic systolic heart failure, chronic kidney disease, type 2 diabetes mellitus, and cerebrovascular disease. An optometry evaluation documented that the resident had cataracts and had been dispensed glasses. However, the MDS assessment indicated that the resident did not use corrective lenses, despite evidence to the contrary. During interviews, the resident confirmed wearing eyeglasses, and the surveyor observed two pairs of eyeglasses on the resident's nightstand. The Corporate MDS Nurse initially was unaware of the resident's use of eyeglasses but later acknowledged that the resident did wear them and that the MDS had been coded incorrectly. The failure to accurately code the use of corrective lenses was identified through record review, resident interview, and staff interview.