Failure to Accurately Code MDS Assessment for Visual Impairment
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of vision for a resident with a history of cardiac arrhythmia, dementia, and essential hypertension. The resident's electronic medical record included an ophthalmology consultation that documented bilateral cataracts and blurred vision, with cataract surgeries scheduled but delayed due to a hospital stay. Despite this, both the Significant Change in Status and the most recent MDS assessments completed by two different MDS nurses indicated the resident had adequate vision and corrective lenses, with no mention of visual impairment or cataracts in the care plan. Interviews with the resident confirmed ongoing difficulty with vision, and staff interviews revealed that the MDS nurses were unaware of the ophthalmology findings at the time of assessment. Both nurses acknowledged that the resident should have been coded for visual impairment based on the available medical information. The administrator also confirmed that the MDS assessments should have accurately reflected the resident's medical condition.