Failure to Accurately Code Resident Diagnosis on MDS Assessment
Penalty
Summary
The facility failed to accurately complete a comprehensive assessment for one resident in the area of diagnoses. The resident was admitted with multiple significant medical conditions, including congestive heart failure, end stage renal disease, atrial fibrillation, and hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease. Physician orders included medications for heart failure and atrial fibrillation, and a care plan was initiated to address cardiovascular risk, including interventions such as medication administration, monitoring for edema, and weight monitoring. Despite these documented diagnoses and interventions, the admission Minimum Data Set (MDS) did not include heart failure as a diagnosis. During interviews, the MDS Coordinator acknowledged that the resident had a diagnosis of congestive heart failure and reviewed the resident's records, confirming that the diagnosis was not coded correctly on the MDS. The MDS Coordinator explained her usual practice for coding diagnoses and recognized the error in this case. The Director of Nursing also confirmed that all MDS assessments should be coded correctly for relevant diagnoses.