Failure to Accurately Code UTI on MDS Assessment
Penalty
Summary
The facility failed to accurately code a urinary tract infection (UTI) on the quarterly Minimum Data Set (MDS) assessment for one resident. The resident was admitted to the facility with a diagnosis of cerebral infarction and was later transferred to the hospital due to unresponsiveness. Hospital records indicated that the resident was diagnosed with a multidrug-resistant E. coli UTI and treated with antibiotics. Upon return to the facility, the quarterly MDS assessment did not reflect the UTI diagnosis, as the infection item was not marked. Interviews with facility staff revealed that the MDS Coordinator did not code the UTI, believing it should only be coded if the infection occurred while the resident was in the facility. The Resident Assessment Director and the Vice President of Clinical Reimbursement both confirmed that the UTI should have been coded according to the RAI Manual, as the diagnosis and treatment occurred within the required 30-day look-back period. The MDS Director acknowledged that there was no audit process in place to ensure the accuracy of MDS assessments, and regional audits had not yet focused on UTI coding errors.