Inaccurate MDS Coding for Incontinence and Suprapubic Catheter
Penalty
Summary
The deficiency involves inaccurate completion of the MDS assessments, resulting in resident assessments that did not accurately reflect two residents' bladder and bowel status and use of urinary devices. For one resident with traumatic brain injury, tracheostomy, and severely impaired cognitive skills (BIMS of 0), the admission and quarterly MDS assessments coded urinary incontinence (H0300) as "frequently incontinent" instead of "always incontinent," and bowel incontinence (H0400) as "frequently incontinent" instead of "always incontinent." Clinical record review and staff interview confirmed that this resident had been incontinent of both bowel and bladder since admission, indicating that the MDS coding did not match the resident's actual condition. For another resident with flaccid neuropathic bladder and depression, the clinical record and care plan documented the use of a suprapubic indwelling urinary catheter beginning in early April 2024. However, the quarterly MDS assessment coded Section H0100C as "yes" for an ostomy, indicating the resident had an ostomy rather than correctly identifying the suprapubic catheter as an indwelling catheter per RAI Manual guidance. During interview, the clinical reimbursement coordinator acknowledged that this was incorrect documentation because the resident had a suprapubic catheter and not an ostomy, confirming that the MDS assessment did not accurately reflect the resident's urinary device status.
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