Inaccurate MDS Assessment for Anticoagulant Medication
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status, specifically for one resident. A clinical record review for this resident revealed a discrepancy in the quarterly Minimum Data Set (MDS) dated November 6, 2024. The facility staff had assessed the resident as receiving an anticoagulant medication during the last seven days of the assessment period. However, further review of the clinical records showed no evidence that the resident had received such medication during that time. An interview with the Director of Nursing confirmed that the MDS was coded in error regarding the administration of the anticoagulant medication.
Plan Of Correction
Step 1: Re-education on coding accuracy. Please obtain signatures of all applicable MDS coordinators from the facility (See attached Section N of the RAI Manual): Immediate Remedy and Re-education/MDS modification submitted by Regional. Step 2: Audit most recently completed OBRA MDS Assessment 100% of current residents, any coding errors identified to be fixed. **See Audit tool. **Tip** You can pull an MDS item response specific for MDSs and how this question N0415E was coded- then review the MAR for that time frame. To be completed by Facility MDS. Completed Audit to be reviewed by Regional MDS. Step 3: Continued Audit needs: 10 completed MDSs to be reviewed by 2nd MDS coordinator and/or regional. To be completed weekly x 4 weeks: