Failure to Accurately Reflect Indwelling Urinary Catheter on MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status by not indicating the presence of an indwelling urinary catheter on the resident's Quarterly MDS. The resident, a female with multiple diagnoses including high blood pressure, diabetes, Parkinson's disease, hypothyroidism, and systemic lupus erythematosus, was admitted to hospice care and had an indwelling urinary catheter placed due to urinary retention. Documentation in the clinical record, care plans, and hospice plans of care confirmed the presence and ongoing management of the catheter, including notes of catheter care and replacement. Despite this, the Quarterly MDS assessment did not mark that the resident had an indwelling urinary catheter. The MDS nurse stated that the omission was due to reliance on the clinical record and Point of Care charting, which did not reflect the catheter, and acknowledged that the nurse's note indicating catheter replacement was overlooked. The Director of Nursing also confirmed that there was no physician order for the catheter in the clinical record and no documentation of catheter care, and agreed that the MDS should have indicated the presence of the catheter. Interviews with nursing staff and review of the resident's records revealed that the indwelling urinary catheter had been in place since the resident's admission to hospice care, and both facility and hospice staff were responsible for its care. The facility's policy and the CMS RAI Manual require accurate assessment and documentation of such devices, including direct observation and review of all relevant records. The failure to accurately code the presence of the indwelling urinary catheter on the MDS was attributed to incomplete documentation and oversight during the assessment process.