Inaccurate MDS Medication Coding for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Section N, Medications, on the Minimum Data Set (MDS) assessments for two residents. For one resident with intact cognition, the MDS indicated use of an antiplatelet medication, but review of the Medication Administration Record (MAR) for the relevant month showed no administration of such medication, and the MDS Coordinator confirmed the resident was not on an antiplatelet. For another resident with severely impaired cognition, the MDS assessment indicated use of a diuretic, but neither the physician orders nor the medical record supported this, and both the MDS Coordinator and Director of Nursing acknowledged the resident was not prescribed a diuretic and that this was likely a coding error. Additionally, the facility did not have a policy in place for ensuring MDS accuracy.