Failure to Accurately Complete MDS Assessment for Dialysis Treatment
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident who was admitted with multiple diagnoses, including End Stage Renal Disease (ESRD), Chronic Obstructive Pulmonary Disease, Diabetes, Vascular Dementia, and mobility issues. Medical records and the Medication Administration Record (MAR) indicated that the resident was ordered and received hemodialysis treatments on specific days following admission. The resident's comprehensive care plan also documented dialysis related to ESRD. However, the admission MDS assessment did not reflect that the resident received dialysis treatments while at the facility. This discrepancy was confirmed by the Clinical Reimbursement Specialist during a review of the medical record and the MDS assessment.