Inaccurate Admission Assessment Coding
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure the accuracy of an admission assessment for one resident. The admission assessment, dated 03/07/25, indicated that the resident, who had a diagnosis of atrial fibrillation and a BIMS score of 15, had received an anticoagulant medication during the look back period. However, a review of the medication administration record and treatment administration record for March 2025 did not show that the resident had actually received an anticoagulant. During an interview, the MDS coordinator confirmed that the assessment had been coded inaccurately and acknowledged that the resident should not have been coded as having received an anticoagulant.