Inaccurate MDS Assessment for Bladder Appliance Use
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manual, Section H requires documentation of the use of bladder and bowel appliances, including indwelling catheters, during the 7-day look-back period. Medical record review showed that the resident had a history of urinary retention and previously had an indwelling urinary catheter, which was ordered to be removed after 48 hours. Subsequent clinical notes confirmed that the catheter had been removed and the resident was occasionally incontinent of bladder and bowel, but was urinating effectively without the catheter. Despite this, the quarterly MDS assessment inaccurately indicated that the resident had an indwelling catheter during the look-back period. Observations on multiple dates confirmed that the resident did not have a catheter in place, and interviews with the resident, the MDS Coordinator, and the Director of Nursing all verified that the MDS was not accurately coded. The deficiency was identified through review of the MDS, medical records, and staff interviews, which established that the facility did not ensure the accuracy of the resident's MDS assessment regarding the presence of an indwelling urinary catheter.