Inaccurate MDS Assessment Coding for Insulin Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for a resident with diagnoses including Parkinson's disease, diabetes, and schizophrenia. The resident's quarterly MDS assessment indicated insulin use, but a review of the Medication Administration Record (MAR) for the assessment period showed the resident only received Ozempic (semaglutide), a non-insulin injectable medication for diabetes. There was no documentation that the resident received insulin during the assessment period. The MDS Coordinator stated she coded insulin use because Ozempic lowers blood sugar, but later acknowledged uncertainty and sought further guidance. The DON clarified that Ozempic should be coded as an injected medication, not as insulin. Facility policy requires documentation to be consistent with physician orders and insulin administration records.