Incorrect MDS Coding of Anticoagulant Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident regarding the use of anticoagulant medication. The resident, who had a history of hemiplegia, hemiparesis following a cerebral infarction, diabetes mellitus, and generalized muscle weakness, was admitted and had an order for Plavix (clopidogrel), an antiplatelet medication, to be administered daily for a cerebrovascular accident. The MDS, dated shortly after admission, incorrectly indicated that the resident received anticoagulant medication. During interviews and record reviews, it was clarified by the MDS Nurse that Plavix is classified as an antiplatelet, not an anticoagulant, and should not have been coded under the anticoagulant section (N0415E) of the MDS. The DON confirmed that accurate medication documentation on the MDS is essential for proper care planning and that anticoagulant and antiplatelet medications are coded separately due to their different mechanisms and uses. The CMS RAI User's Manual also specifies that antiplatelet medications should be coded distinctly from anticoagulants.