Inaccurate MDS Coding for Falls and Indwelling Catheter
Penalty
Summary
The deficiency involves inaccurate coding of Minimum Data Set (MDS) assessments for two residents in the areas of accidents and urinary catheter use. One resident with a history of muscle weakness, a left hip fracture, and mild cognitive impairment was admitted on an unspecified date and experienced three falls between late July and October: one fall with major injury, one fall with no injury, and one fall with minor injury. However, the quarterly MDS dated in October coded only one fall with minor injury since the previous assessment, omitting the documented fall with major injury and the fall with no injury. During an interview, the MDS Coordinator reviewed the resident’s record and confirmed that three falls had occurred since the prior assessment and acknowledged that the MDS should have been coded to include one fall with no injury and one fall with major injury in addition to the minor injury fall. The DON stated it was her expectation that MDS assessments be coded accurately for accidents. The second resident was admitted with neuromuscular dysfunction of the bladder and neurogenic bladder and had physician orders dated in April to flush a suprapubic catheter with 60 cc of normal saline every shift and to provide urinary catheter care every shift. The care plan initiated in April documented the presence of an indwelling suprapubic catheter, and the December and January MARs and TARs showed that nurses consistently documented suprapubic catheter flushes and urinary catheter care every shift over several days. Despite this, the resident’s most recent quarterly MDS indicated that the resident did not have an indwelling urinary catheter. Upon review, the MDS Coordinator confirmed that the resident was coded as not having an indwelling urinary catheter and stated that an as-needed MDS nurse had coded the bladder and bowel section incorrectly, noting that the suprapubic catheter was present when the assessment was completed. The DON stated she expected MDS assessments to be coded accurately for each resident.
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