Inaccurate MDS Coding for Medications and UTI
Penalty
Summary
The facility failed to accurately code medications and a urinary tract infection (UTI) on the Minimum Data Set (MDS) assessments for four out of fifteen residents reviewed. Specifically, one resident's Medication Administration Record (MAR) showed an order for apixaban, an anticoagulant, but their MDS assessment did not document receipt of an anticoagulant during the lookback period. Another resident's MAR listed trazodone, an antidepressant, but the MDS assessment did not reflect that the resident received an antidepressant, instead incorrectly indicating use of an antipsychotic. A third resident's MAR showed an order for clopidogrel bisulfate, an antiplatelet, but the MDS assessment incorrectly coded the resident as having received both an anticoagulant and an antiplatelet, contrary to the RAI manual instructions not to code antiplatelets as anticoagulants. Additionally, a fourth resident's MDS assessment indicated receipt of an anticoagulant, but the MAR did not show an order for such medication. This resident's MAR did include physician orders for antibiotics to treat a UTI, but the MDS assessment did not document the UTI during the lookback period. The facility's policy required that assessments be accurate and reflective of the resident's status at the time of assessment, completed by qualified staff. The DON acknowledged the MDS assessments were coded incorrectly.