Failure to Accurately Code Significant Weight Loss on MDS
Penalty
Summary
The facility failed to ensure accurate coding of weight loss on the Minimum Data Set (MDS) for a resident with severe cognitive impairment. The resident experienced significant weight fluctuations over a three-month period, including a weight loss of over 14% in nine weeks and over 16% in twelve weeks, as documented in the Weights and Vitals Summary. Despite these documented losses, Section K: Swallowing/Nutritional Status of the resident's significant change MDS was incorrectly coded as having no or unknown weight loss or gain since the last assessment period. Interviews with facility staff revealed that the dietary manager, who was responsible for completing Section K of the MDS, did not realize the error and acknowledged that the resident had experienced weight loss, which had been discussed in high-risk team meetings. The registered dietician noted inconsistencies in the recorded weights and stated that the resident's intake was poor, further supporting the presence of significant weight loss. The director of nursing confirmed that the resident was being monitored for weight loss and should have been coded accordingly on the MDS. The facility's policy and the CMS RAI User's Manual require accurate and comprehensive assessment and coding of resident weight changes, which was not followed in this instance.