Inaccurate MDS Assessment of Medication Administration
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's medication on the Minimum Data Set (MDS) as required by facility policy. A resident was admitted with diagnoses including unspecified dislocation of the left hip, abnormalities of gait and mobility, and hyperlipidemia. The resident was prescribed Ozempic, a weekly injection for weight loss, and not insulin. However, the MDS assessment incorrectly documented that the resident received insulin for 7 days during the look-back period and also inaccurately recorded the frequency of Ozempic administration as daily injections for 7 days, rather than the correct weekly administration. Interviews with the resident, the MDS nurse, and the DON confirmed that the resident was not receiving insulin and that Ozempic was not classified as insulin. The MDS nurse acknowledged the errors in both the classification and frequency of the medication on the MDS. Facility policy required all persons completing any portion of the MDS to attest to the accuracy of the information, and documentation was to be objective, complete, and accurate. These requirements were not met in this instance.