Inaccurate MDS Coding for PASRR Status and Indwelling Catheter
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents’ clinical status for two residents, resulting in inaccurate coding of key assessment items. For one resident with multiple diagnoses including schizophrenia – bipolar type and anxiety, a Significant Change MDS assessment documented “no” in Section A1500 regarding whether the resident was considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, despite the presence of a Level II PASRR dated 9/14/25 in the electronic medical record; the MDS coordinator later acknowledged this should have been coded “yes.” For another resident with end stage renal disease dependent on dialysis, a Quarterly MDS assessment documented “yes” for an indwelling catheter in Section H-A, but an observation of the resident in her room showed she did not have a Foley catheter, and the MDS coordinator stated that the assessment had been coded in error.
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