Inaccurate MDS Hearing and Hearing Aid Coding for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate MDS assessment for one resident by not properly assessing and coding the resident’s hearing status and use of hearing aids. The resident had diagnoses including a left femur fracture, Parkinson’s disease, and dysphagia, and was documented as lacking capacity to understand and make decisions. An MDS assessment dated 10/29/2025 showed the resident had severely impaired cognitive skills for daily decision making and was totally dependent on staff for oral hygiene, toileting hygiene, and lower body dressing. A Social Services Assessment dated 10/27/2025 documented that the resident had both right and left hearing aids. During an interview and concurrent record review, the MDS nurse acknowledged that Section B of the MDS, which covers hearing, speech, and vision, was completed inaccurately. The nurse stated that the hearing item (B0200) was coded as 0 (Adequate) instead of 1 (Minimal difficulty), and the hearing aid item (B0300) was coded as 0 (No) instead of 1 (Yes), despite the Social Services Assessment indicating the resident had hearing aids. The MDS nurse reported she did not see the resident using hearing aids at the time of the assessment and did not follow the RAI Section B guidelines, which require ensuring the resident is using their normal hearing appliance, reviewing the medical record, and consulting family and staff. The DON confirmed that MDS assessments must be completed accurately to meet resident needs and develop an appropriate plan of care, and facility policy and the CMS RAI User’s Manual both require accurate, guideline-based resident assessments.
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