Inaccurate MDS Coding for Vision 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 diagnosis of glaucoma and a history of visual impairment. The resident was admitted with a diagnosis of glaucoma and reported being nearly blind, requiring all lights on in his room to see. Despite this, the MDS admission assessment coded the resident as having adequate vision, and the Social Worker Assistant who completed the assessment stated he was not aware of the resident's blindness at the time. The Social Worker Assistant also did not review the resident's diagnoses or past history and did not complete the care area assessment, which had triggered a care plan for vision. Interviews revealed that the Social Worker Assistant later acknowledged the resident had shared information about his visual impairment and admitted the vision section of the MDS should have been coded as impaired. The Administrator confirmed that accurate MDS coding is expected to ensure staff are aware of residents' care needs. The deficiency was identified through observations, record review, and interviews, which demonstrated a lack of accurate assessment and documentation of the resident's vision status.