Inaccurate MDS Coding for Diagnoses and Infections
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected residents' clinical status for two residents. For one resident with diagnoses including chronic kidney disease and dementia, review of the quarterly MDS dated November 11, 2025, showed Section I2300 coded to indicate a urinary tract infection (UTI) within the last 30 days. However, review of this resident's clinical record did not reveal any evidence that the resident had a UTI in the 30 days prior to that MDS assessment date. For another resident with diagnoses including seborrheic dermatitis and squamous cell cancer of the scalp, observation revealed a large, scabbed area covering the entire top of the head. Review of this resident's quarterly MDS assessments dated May 15, 2025, August 12, 2025, and November 11, 2025, showed that cancer was not documented in Section I as a diagnosis. Interviews with the RN Assessment Coordinator, the DON, and the Nursing Home Administrator confirmed that these MDS assessments should have documented cancer as an active diagnosis.
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