Inaccurate MDS Coding for Resident With Nonverbal Status and Hearing Loss
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of the Minimum Data Set (MDS) for one resident in the area of hearing and speech. The resident was admitted with diagnoses including expressive language disorder, bilateral sensorineural hearing loss, dysphagia, other drug-induced secondary parkinsonism, and cognitive communication deficit. Physician orders included a referral for speech therapy evaluation and treatment with a recommended non-verbal communication board. Multiple psychiatric notes documented that the resident was nonverbal and that assessments were completed via chart review and staff input because the resident used paper and pencil to answer questions. The resident’s care plan and progress notes consistently identified significant communication and hearing impairments. The care plan documented potential for impaired communication related to impaired hearing, with goals and interventions for the resident to express needs through non-verbal communication, use alternative methods such as writing, and ensure availability and functioning of adaptive equipment. Progress notes described the resident as primarily nonverbal, using a communication board, pen, and paper, and needing special adaptive equipment, including a communication board and written instructions/gestures for hearing loss, while also stating there were no cognitive limitations. A speech therapy evaluation further documented that the resident was nonverbal, had no speech clarity, used a notepad to communicate, had profound hearing loss with highly impaired ability to hear, and required skilled therapeutic interventions due to these physical impairments. Despite this documentation, multiple MDS assessments for the resident’s Section B (Hearing, Speech, Vision) were coded as having adequate hearing and clear speech on several quarterly and annual assessments. During interviews, the resident was observed to be nonverbal and communicating via notebook, and multiple staff members, including CNAs, a CMA, the Activities Director, the Director of Rehab, and the Social Services Director, all stated that the resident did not speak and used a notebook or communication board to communicate, and that the resident had hearing impairment. The MDS Coordinator, who was responsible for completing the resident’s MDS assessments, stated that these MDS Section B assessments were coded as reflecting adequate hearing and speech and acknowledged that the MDS Section B should have been accurate but was not.
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