Inaccurate MDS Coding for Administered Medications
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded regarding the administration of specific medications for two residents. For one resident, the MDS indicated that no hypoglycemic medications were administered during the assessment period, despite the Medication Administration Record (MAR) showing that semaglutide, a hypoglycemic medication used for diabetes mellitus, was given within the review period. For another resident, the MDS recorded that no antianxiety medications were administered, while the MAR documented that buspirone, an anxiolytic medication, was given multiple times during the same period. These discrepancies were confirmed through interviews with the registered nurse responsible for completing the MDS, who acknowledged the errors after reviewing the medical records. The nurse verified that the medications in question should have been coded on the MDS based on their pharmacological classification and actual administration as documented in the MAR. The facility did not provide a policy on MDS completion and accuracy when requested.