Inaccurate MDS Coding for Resident Behaviors
Penalty
No penalty information released
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Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident with dementia. During the 7-day lookback period, progress notes documented that the resident exhibited behaviors such as spitting, urinating on the floor, and refusing care, including declining a nursing assessment and covering his head with a sheet. Despite these documented behaviors, the resident's admission MDS assessment was only coded for verbal behaviors directed toward others for 1-3 days, with no coding for other behavioral symptoms or rejection of care. Staff interviews confirmed that the MDS should have included rejection of care and other behaviors, and the omission was acknowledged as a coding error.