Inaccurate MDS Coding of Resident Hearing Status
Penalty
Summary
Failure to complete an accurate comprehensive assessment occurred when the facility did not correctly code a resident’s hearing status on the MDS. The resident reported being hard of hearing and stated she had been trying to obtain hearing aids, but her insurance would not cover them. The baseline care plan identified the resident as hearing impaired, and the comprehensive care plan included a hearing deficit focus with interventions such as validating the resident’s message by repeating it aloud. Appointment notes documented ongoing efforts to coordinate with an ENT provider and a mobile hearing service regarding hearing aids and hearing testing. The resident’s diagnoses included bilateral hearing loss. Despite this information, the MDS assessment documented that the resident had adequate hearing without hearing aids or other hearing appliances. The MDS Coordinator stated she coded the resident as having adequate hearing because, during her own interactions, the resident did not report difficulty hearing and appeared to respond as though she could hear. She also stated that her assessments were based solely on her own interactions with residents unless something was noted in the progress notes, and she did not identify the prior documentation of the resident’s hearing deficit. A CNA reported needing to speak to the resident with an elevated voice because the resident did not seem to hear well. The DON stated the MDS should be accurate and follow the diagnoses, and facility policy required that every MDS item accurately reflect the resident’s status during the look-back period and that the RN Coordinator verify encoded data against clinical documentation before transmission.
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