Inaccurate MDS Coding of Resident Communication and Mental Status
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident when the Quarterly MDS with an Assessment Reference Date of 01/12/2026 did not correctly reflect the resident’s communication and mental status. Record review showed that in Section C, question C0100, which asks whether the Brief Interview for Mental Status (BIMS) should be conducted, the resident was coded as 0 – no (resident is rarely/never understood). However, during an interview on 02/18/2026, the resident was able to hear and understand questions without difficulty and was able to clearly voice answers. In a subsequent interview, the social worker responsible for completing Section C of the MDS acknowledged that the resident was able to be understood and that coding C0100 as 0 was inaccurate, and the DON also confirmed that this MDS item was not coded accurately.
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