Inaccurate MDS Coding for Rejection of Care
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of rejection of care. The resident, who had a diagnosis including anxiety disorder and moderately impaired cognition, was admitted with a care plan that addressed behavior problems such as noncompliance with tube feedings and ordered oral diet. Review of the medical record and Medication Administration Record (MAR) showed that the resident refused medications and care on multiple occasions within the seven-day look-back period for the MDS assessment. Despite these documented refusals, the MDS assessment was not coded to reflect any rejection of care. Interviews with facility staff revealed that the Social Worker (SW), who was responsible for completing the rejection of care section on the MDS, only reviewed nurses' notes and did not check the MAR for refusals. The SW admitted to being unsure where to find information about rejection of care in the medical records and confirmed that the resident's refusals should have been coded on the MDS. The administrator stated an expectation for accurate MDS coding.