Inaccurate MDS Assessment Coding for Diabetes Medication
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for one resident, resulting in incorrect documentation of the resident's medication administration. Specifically, the MDS for this resident repeatedly indicated that insulin was administered one time during the seven-day look-back period for multiple quarterly and annual assessments. However, a review of the Medication Administration Records (MARs) showed that the resident was actually receiving Trulicity, a non-insulin injectable diabetes medication, and not insulin during those periods. The error was confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged that the MDS coding for insulin administration was incorrect and should have been recorded as zero days. The resident involved had a medical history including a bacterial bone infection, Type 2 diabetes, and an irregular heartbeat. The deficiency was cited under 28 Pa. Code 211.5(f)(x) for inaccurate medical records.