Failure to Accurately Code Osteomyelitis Diagnosis on Discharge MDS
Penalty
Summary
The facility failed to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected the resident’s active diagnosis of osteomyelitis. The resident, an adult male admitted with a history including an open wound of the foot, open wound of the left great toe, and diabetes mellitus with hyperglycemia, was referred to the hospital due to concern for osteomyelitis of the left foot. Hospital records, including MRI imaging, documented left calcaneal osteomyelitis and possible left 5th toe osteomyelitis, and the resident was admitted for management of a urinary tract infection and a left open wound concerning for osteomyelitis, with a plan for antibiotic therapy prior to return to the facility. Despite this, the resident’s discharge MDS did not include osteomyelitis as a diagnosis, even though the resident’s care plan identified a need for IV therapy related to osteomyelitis and listed interventions such as administering IV fluids per order, auscultating lung sounds, monitoring the IV site for infection, and notifying the physician of signs and symptoms of infection or complications. During interviews, the MDS LVN stated that the MDS assessment is intended to depict the care being provided to the resident and that all active diagnoses should be included. He explained that floor nurses were responsible for updating the MDS upon initiation of a new diagnosis and that he only reviewed the MDS quarterly. He further stated that if a diagnosis was missing from the MDS, he viewed it as a reimbursement issue rather than a risk to resident care and reported that he had not received in-services on accurate MDS completion. The Administrator stated that he primarily focused on the BIMS score and was unsure whether resident diagnoses had to be included in the MDS, acknowledging that omitting medical diagnoses would not show the resident’s full clinical picture. He indicated that floor nurses and MDS nurses were responsible for accurate completion of the MDS and could not recall the last in-service provided. The facility’s Resident Assessment policy stated that a comprehensive assessment would be completed when a significant change was determined based on RAI manual criteria, but the osteomyelitis diagnosis was not reflected on the resident’s discharge MDS.
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