Inaccurate Coding of MDS Assessments for Discharge and Dialysis
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for two residents. One resident, who was discharged from the facility, had a progress note indicating discharge home with a friend and receipt of medications, but the discharge MDS assessment incorrectly documented discharge to a short-term general hospital. This miscoding was identified during staff interviews, where it was acknowledged as a keying error. Another resident with end-stage kidney disease and an active order for hemodialysis three times weekly was not coded for dialysis on the quarterly MDS assessment. The MDS Coordinator explained that the assessment was completed by a remote nurse in training, who had the correct information but failed to code dialysis on the assessment due to oversight. Interviews with facility leadership confirmed that MDS assessments are expected to accurately reflect residents' care needs.