Inaccurate MDS Coding of Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s comprehensive assessment accurately reflected a significant weight loss of more than 10% over six months. The resident had diagnoses including vascular dementia without behavioral disturbances and adult failure to thrive. A weight of 122.0 lbs was recorded on 5/13/25, and the resident’s care plan dated 6/10/25 identified risk for malnutrition related to adult failure to thrive, altered nutrition-related bloodwork, a BMI less than 23, and significant weight changes, with interventions to assess intakes, bloodwork, and weights, and to monitor for significant changes. A subsequent weight of 108.6 lbs on 11/16/25 represented a 13.4 lb (10.984%) loss over six months compared to the 5/13/25 weight. Despite this documented weight loss, the quarterly MDS assessment dated [DATE] did not identify that the resident had experienced a weight loss of 5% or more in the last month or 10% or more in the last six months. The RD, who was responsible for completing Section K (Swallowing and Nutritional Status) of the MDS, acknowledged that Section K of the 12/4/25 MDS was coded incorrectly, explaining that she used an incorrect baseline weight and failed to calculate the weight change using the appropriate six-month look-back period from the Assessment Reference Date. The DON stated that the MDS should accurately reflect a resident’s care for all sections, including swallowing and nutritional status, and acknowledged that this MDS did not accurately reflect the resident’s significant weight loss. When requested, the facility did not provide a policy on comprehensive assessments.
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