Inaccurate Coding of Significant Change MDS Assessment
Penalty
No penalty information released
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Summary
The facility failed to accurately code a significant change Minimum Data Set (MDS) assessment for one resident. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, muscle weakness, and bipolar disorder. Documentation showed the resident was admitted to hospice care, with a hospice certification and physician's order confirming the start of hospice services. However, the significant change MDS assessment did not reflect the resident's hospice status, as the section for hospice care was not marked. The MDS coordinator confirmed that the assessment was related to the resident's transition to hospice but acknowledged that hospice was not coded on the MDS, resulting in an inaccurate assessment.