Inaccurate MDS Assessment for Catheter Status
Penalty
Summary
A deficiency was identified when a review of a resident's admission Minimum Data Set (MDS) assessment indicated that the resident had an indwelling catheter, as documented in section H, Bladder and Bowel. However, further examination of the clinical record revealed no evidence that the resident actually had an indwelling catheter at the time of the assessment. This discrepancy was confirmed during an interview with a licensed staff member, who acknowledged that the MDS had been coded incorrectly and that the resident did not have an indwelling catheter. The failure to accurately assess and document the resident's status resulted in an inaccurate MDS assessment for this individual.
Plan Of Correction
Resident 29 was discharged. Section H of MDS submitted within the last 14 days will be reviewed to assure clinical record and MDS coding is consistent with resident assessment of bowel and bladder. Administrator/Designee will educate clinical reimbursement staff on ensuring MDS coding is consistent with clinical record for resident assessment of bowel and bladder status. Random audits of Section H of MDS submitted will be conducted to assure clinical record and MDS coding is consistent with resident assessment of bowel and bladder. Audits will be done weekly x4, then monthly x2 or until compliance is achieved. Results will be discussed in monthly QAPI meeting.