Inaccurate MDS Coding for Bladder, Bowel, and Medication Status
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for two residents in the areas of bladder and bowel status, and medication administration. For one resident, the nursing progress note indicated that a urinary catheter was discontinued per order without difficulty or complaint, yet the admission MDS assessment incorrectly coded the resident as having an indwelling catheter and being frequently incontinent of urine. The MDS Coordinator acknowledged that the assessment should have reflected the absence of a catheter and that the incontinence status was auto-populated based on nurse aide responses. For another resident, the quarterly MDS assessment was coded to indicate the use of anticoagulant medication. However, a review of the Medication Administration Record showed that the resident only received an anticoagulant for three days, and not during the required 7-day look-back period for the assessment. The MDS Coordinator confirmed that the resident should not have been coded as receiving anticoagulants, as the medication had been discontinued prior to the look-back period. The Director of Nursing also confirmed that both assessments should have been coded accurately.