Inaccurate MDS Coding for Resident Receiving Tube Feeding
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident with a history of stroke and dysphagia who had a percutaneous endoscopic gastrostomy (PEG) tube for nutritional support. Despite physician orders and documentation indicating the resident was receiving specialized nutritional supplements via PEG tube, the quarterly MDS assessment did not reflect the use of a feeding tube, nor did it include the proportion of total calories and average fluid intake received through tube feeding. Interviews with facility staff revealed that the Registered Dietician (RD), who was responsible for coding the Swallowing/Nutritional Status section of the MDS, did not complete this section accurately. The RD acknowledged missing the required coding for the feeding tube and related nutritional information. The MDS Coordinator and Director of Nursing confirmed that the MDS should have been completed accurately, and the Administrator also stated that the MDS should be coded correctly.