Inaccurate MDS Coding of Resident Tobacco Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments were accurately coded to reflect residents’ current tobacco use status. Two residents who were identified as smokers through interviews with the surveyor and facility documentation were coded as non-smokers on their annual MDS assessments. One resident reported to the surveyor that they were a smoker, and the facility’s smoking list and a prior Smoking Evaluation dated 9/2/2025 identified this resident as an independent smoker. However, the resident’s annual MDS assessment completed on 9/22/2025 documented “No” for tobacco use in section J1300. Similarly, another resident informed the surveyor that they were a smoker, and the facility’s smoking list and a Smoking Evaluation dated 12/3/2025 showed that this resident was also an independent smoker. Despite this, the resident’s annual MDS assessment completed on 12/06/2025 recorded “No” for tobacco use in section J1300. During interviews, the MDS Coordinator acknowledged that tobacco use should have been captured on the annual MDS for one of the residents, and the Corporate Clinical Lead was informed by the surveyor that the other resident’s annual MDS did not reflect current tobacco use. These findings demonstrate that existing information about residents’ smoking status was not accurately incorporated into their MDS assessments.
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