Failure to Accurately Code Dialysis in MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident who was receiving dialysis treatment. Specifically, the MDS for a female resident with end-stage renal disease and hypertension did not indicate that she was undergoing dialysis, despite her care plan and interviews confirming that she received dialysis three times a week. The resident's care plan included multiple interventions and monitoring related to her dialysis treatment, and the resident herself confirmed her ongoing dialysis schedule and the facility's involvement in her care. Interviews with the MDS Coordinator revealed that dialysis treatment was not coded in the resident's MDS assessment due to an oversight, and the Coordinator acknowledged responsibility for the error. The Director of Nursing confirmed that MDS Coordinators are expected to complete assessments accurately and on time, and recognized that missing information in the MDS could result in incomplete capture of the resident's care needs. The facility's policy required comprehensive assessments using the current RAI, including special treatments and procedures such as dialysis.