Failure to Accurately Code MDS for Resident with Cancer and Hematuria
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for one resident, as identified through record review, review of the RAI User's Manual, and staff interview. The resident had a history of hospitalizations for urinary tract infection and hematuria, with an active diagnosis of malignant neoplasm of the bladder and was prescribed Bactrim DS, an antibiotic. Despite this, the significant change and quarterly MDS assessments did not reflect the resident's cancer diagnosis in Section I0100, nor did they indicate internal bleeding in Section J1550D, even though hematuria was present. Additionally, the quarterly MDS failed to code the use of an antibiotic in Section N0415F. These omissions were confirmed during an interview with an MDS staff member, who acknowledged the failure to accurately code the MDS. The lack of accurate coding meant that the resident's assessment did not fully reflect their current status, as required by the RAI User's Manual guidelines for active diagnoses, health conditions, and medication use during the specified look-back periods.