Inaccurate MDS Coding of Resident Diet Status
Penalty
Summary
Surveyors identified that the facility failed to ensure an accurate MDS assessment for one resident when the resident’s diet was incorrectly coded. The resident was an older female with multiple diagnoses including acute and chronic respiratory failure with hypoxia, neuromuscular bladder dysfunction, insomnia, morbid obesity, type 2 diabetes mellitus, bipolar disorder, tracheostomy status, and polyphagia. Her significant change MDS assessment dated 02/17/2025 documented that she was on a mechanically altered diet, despite other records and observations indicating otherwise. The resident’s comprehensive care plan dated 03/03/2025 listed a focus of a regular diet with regular texture and consistency, and active orders as of 03/16/2026 showed a regular diet, regular texture, and regular consistency per hospice with a start date of 12/02/2025. On observation, the resident was seen being assisted with eating a lunch consisting of regular food with regular texture and consistency, and her meal ticket also reflected a regular diet. In interviews, the resident stated she had been on a regular diet since admission. MDS staff acknowledged errors in the MDS, including missing the resident’s CPAP under non-invasive mechanical ventilator and failing to reflect the regular diet on the significant change MDS, and stated they did not know how these items were missed. The ADON and the administrator both confirmed that the resident was on a regular diet and emphasized that MDS accuracy is important to show what care residents need, consistent with the facility’s MDS policy and the CMS RAI User’s Manual requirement that assessments accurately reflect the resident’s status.
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