Inaccurate MDS Coding for Dialysis and Hospice Care
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. For one resident with end stage renal disease (ESRD) and a history of hemodialysis, the facility did not accurately code dialysis care on multiple MDS assessments, including quarterly, annual, and Medicare 5-day assessments. Despite documentation in the resident's face sheet, physician orders, care plan, progress notes, and dialysis communication forms confirming ongoing dialysis treatments during the assessment periods, Section O j1 (Dialysis care) was not marked as being received. The MDS Coordinator stated that dialysis was not coded due to a lack of documentation from the dialysis center at the time of assessment, although such documentation was later obtained. For another resident with diagnoses including traumatic brain injury, stroke, vascular dementia, and Alzheimer's disease, the facility failed to accurately code hospice care on a quarterly MDS assessment. Physician orders and the care plan indicated the resident was receiving hospice services for a terminal diagnosis, but Section O k1 (Hospice care) was not marked as being received. The MDS Coordinator acknowledged this was a data entry error upon review. These inaccuracies were identified through observation, interview, and record review.