Inaccurate MDS Coding for Weight Loss Regimens
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments regarding weight loss for two residents. For one resident with a diagnosis of malnutrition and a care plan addressing nutritional concerns, the quarterly MDS assessment was incorrectly coded to indicate the resident was on a physician-prescribed weight loss regimen. However, there were no physician orders for weight loss, and both the Registered Dietitian (RD) and MDS Nurse confirmed that the resident was not intended to lose weight nor prescribed any weight loss medication. The Dietary Technician, who completed Section K of the MDS, did not communicate this coding with the RD or MDS Nurse, leading to the inaccurate documentation. Another resident, with diagnoses including dementia, chronic kidney disease, and diabetes, experienced significant weight loss while receiving a diuretic medication as prescribed by a physician. The resident's MDS assessment was also coded as being on a physician-prescribed weight loss regimen, despite the absence of any such order. The RD and MDS Nurse clarified that diuretic use for fluid management should not be coded as a weight loss regimen unless specifically prescribed for that purpose. The Dietary Technician appeared to have misunderstood the intent of the medication and did not verify the coding with the RD or MDS Nurse. Interviews with facility staff, including the RD, MDS Nurse, and Administrator, revealed a lack of communication and verification regarding the coding of weight loss regimens on the MDS assessments. The Administrator stated that accurate coding is expected and that the Dietary Technician should have consulted with the RD and MDS Nurse when coding weight loss as physician-prescribed. The absence of such communication contributed to the inaccurate MDS documentation for both residents.