Inaccurate MDS Coding for Recent Urinary Tract Infection
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Minimum Data Set (MDS) accurately reflected their clinical status, specifically regarding a urinary tract infection (UTI) within the last 30 days. The resident was admitted with diagnoses including cerebral infarction, UTI, aphasia following cerebral infarction, and hemiplegia/hemiparesis following cerebral infarction. A Significant Change MDS with an Assessment Reference Date of 10/31/2025 coded Section I2300 (UTI in the last 30 days) as "No." However, the resident’s care plan documented a history/diagnosis of UTI, including a diagnosis on 07/01/2025 and another UTI diagnosis associated with a hospital return on 10/15/2025. Further record review showed hospital discharge paperwork for a stay from 10/13/2025 to 10/15/2025 listing a UTI associated with an indwelling urethral catheter as a final active diagnosis dated 10/14/2025. During an interview, an LPN confirmed that the resident had been discharged from the hospital with a UTI diagnosis and that the Significant Change MDS completed on 10/31/2025 should have been coded to reflect a UTI within the last 30 days but was not. In a separate interview, the DON confirmed the expectation that the MDS accurately reflect a UTI on the Significant Change assessment and acknowledged that the resident’s MDS dated 10/31/2025 did not accurately capture this diagnosis.
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