Failure to Accurately Code MDS for Chemotherapy Administration
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident who was receiving chemotherapy. The resident, admitted with diagnoses including colorectal cancer and heart failure, began chemotherapy every two weeks and had a chemotherapy infusion pump placed for a continuous two-day infusion. Nursing and oncologist notes documented the administration of chemotherapy and the presence of the infusion pump during the assessment period. Despite this documentation, the quarterly MDS assessment did not indicate that the resident had received chemotherapy while in the facility or within the last 14 days. Interviews with the Regional MDS Coordinator and other MDS staff revealed that the information was missed during the assessment process, even though they used daily clinical meetings, progress notes, and physician consults to gather assessment data. The Interim DON and Administrator both confirmed that the MDS should be coded accurately, but the error occurred due to missed information.