Inaccurate MDS Assessment Coding for Medication Type
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected her medication status. Specifically, the quarterly Minimum Data Set (MDS) assessment indicated that the resident was receiving an anticoagulant, when in fact she was prescribed and administered clopidogrel, an antiplatelet medication. The MDS nurse acknowledged that this was a coding error, as clopidogrel should have been recorded as an antiplatelet, not an anticoagulant, according to the CMS RAI guidelines. The resident involved was an elderly female with multiple diagnoses, including urinary tract infection, cerebral palsy, heart failure, peripheral vascular disease, hypothyroidism, and cognitive communication deficit, with a BIMS score indicating severe cognitive impairment. Review of her physician orders and medication administration records confirmed she was receiving clopidogrel for blood thinning purposes, but not an anticoagulant. The facility's policy requires comprehensive and accurate assessments in line with CMS guidelines, which was not followed in this instance.