Inaccurate MDS Coding for Pressure Ulcer and Indwelling Catheter
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents’ clinical status for two residents reviewed. For one resident, the admission MDS coded Section M (Skin Conditions) as “No” to the question of whether the resident had one or more unhealed pressure ulcers/injuries. However, the resident’s comprehensive care plan documented an actual unstageable pressure ulcer to the right buttock, and a Weekly-Ulcer Assessment described a Stage II pressure ulcer in the right buttock area near the sacrum, with corresponding physician orders for daily wound care using normal saline and triad. The MDS nurse later acknowledged that, because the resident had a pressure ulcer in the sacral area during the assessment period, Section M should have been coded “Yes” and stated that the inaccurate coding was a mistake by a former MDS nurse. For a second resident, the Medicare 5-day MDS coded Section H (Bladder and Bowel) as “None of the above” for urinary elimination status, despite facility records showing the resident had an indwelling urinary catheter at readmission. The resident’s comprehensive care plan identified the presence of an indwelling urinary catheter with an intervention for catheter care as ordered, and physician orders directed staff to monitor the Foley catheter every shift for leakage, blockage, sediment buildup, or low output. The MDS nurse confirmed that “Indwelling catheter” should have been selected instead of “None of the above” and described this as a coding mistake. The DON stated that all MDS assessments should be coded accurately to provide appropriate care, and the facility’s MDS policy requires that assessments accurately reflect the resident’s status.
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