Inaccurate MDS Assessment Due to Omitted Medication and Diagnosis
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's health and functional status. Specifically, for one resident, the MDS did not include the use of an antianxiety medication (lorazepam) and a diagnosis of migraine, despite both being present in the resident's medical orders. The MDS nurse acknowledged during interview and record review that these items should have been coded in the MDS assessment but were omitted. The nurse stated that she should have reviewed the resident's list of medications and diagnoses to ensure the MDS was accurate and complete. Further review with the Assistant Director of Nursing confirmed that the antianxiety medication was ordered when the resident was admitted to hospice care, and medication for migraine headache was also ordered, though a formal diagnosis of migraine was not found in the record. Both the Administrator and Director of Nursing stated their expectation that the MDS nurse is responsible for gathering all relevant information, including medications and diagnoses, to ensure accurate MDS coding. Professional guidelines require that physician-documented diagnoses and high-risk drug class medications be coded in the MDS when they have a direct relationship to the resident's current status.