Inaccurate MDS Coding for Antibiotic Use
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for a resident reviewed for antibiotic use. During an interview, the resident denied having a urinary tract infection (UTI) and was unsure about taking antibiotics. However, the facility's 30-day admissions matrix indicated that the resident was taking antibiotics for a UTI. Upon further review of the resident's medical records, including pharmacy orders and medication administration records, there was no evidence that antibiotics had been ordered or administered to the resident. The MDS assessment for the resident, dated March 23, 2025, was coded to indicate antibiotic use in Section N0415. The MDS coordinator confirmed that there were no antibiotics found in the resident's current or discontinued medication records. The coordinator explained that the assessment was completed by a weekend MDS coordinator and acknowledged that the coding for antibiotic use was incorrect. The Director of Nursing also agreed that the MDS assessment was inaccurately coded.