Inaccurate Coding of MDS Assessment for Resident Weight Loss
Penalty
No penalty information released
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Summary
Facility staff failed to accurately code the Minimum Data Set (MDS) assessment for a resident with a diagnosis of dysphagia. Medical record review showed that the resident's weight decreased from 213 pounds to 191 pounds between two MDS assessments, representing a 22-pound or 10.3% weight loss over the period. Despite this significant weight loss, staff coded the MDS Section K0300 as 'No' for weight loss, indicating that the resident had not experienced a loss of 5% or more in one month or 10% or more in six months. The MDS Coordinator confirmed during interview that this coding was inaccurate and should have reflected the weight loss.