Inaccurate MDS Coding for Nutritional Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Swallowing/Nutritional Status for one resident. The resident, who had diagnoses of severe protein-calorie malnutrition and dysphagia, was not on a physician-prescribed weight-loss regimen, as documented in the Registered Dietitian's (RD) progress note and confirmed by the care plan, which instead indicated interventions to address unintentional weight loss and underweight status. However, the MDS assessment incorrectly indicated that the resident was on a physician-prescribed weight-loss regimen. The MDS Coordinator stated that the RD completed the relevant MDS section and acknowledged the error, noting she had not noticed the incorrect selection. The Medical Director also confirmed that the resident required additional calories and was not on a weight-loss program.