Failure to Accurately Code MDS for Active Diagnosis
Penalty
Summary
Facility staff failed to accurately code a resident's Minimum Data Set (MDS) assessment by omitting an active diagnosis of hematuria, despite multiple sources documenting the condition. The resident was admitted with hospital discharge orders and documentation indicating hematuria, including a primary diagnosis and care plan for hematuria. However, the admission record did not list hematuria as a diagnosis, and the admission MDS assessment did not document it as an active diagnosis. Subsequent records, including a change in condition evaluation and progress notes, continued to reference hematuria and related symptoms, such as increased confusion, weakness, and the presence of blood in the urine. Interviews with the MDS Coordinator and the DON confirmed that the diagnosis of hematuria was not included in the resident's MDS assessments. The MDS Coordinator stated that symptoms were not added to the active diagnoses list if the facility was not treating the condition in-house, and the DON acknowledged that it was the MDS Coordinator's responsibility to ensure the diagnosis was included. This omission resulted in the resident's MDS not reflecting the active diagnosis of hematuria, as required.