Inaccurate MDS Coding for Medication Administration
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for a resident during their annual assessment. The assessment indicated the resident had limited upper extremity range of motion, was cognitively intact, and had diagnoses including renal insufficiency, amputation, diabetes, heart failure, and atrial fibrillation. The MDS section N0415 documented that the resident was taking an antidepressant and an antibiotic, but did not indicate that the resident was also receiving an anticoagulant, despite this being the case during the assessment period. During an interview, the DON confirmed that the resident did receive an anticoagulant during the MDS review period, but this was not reflected in the assessment. The DON acknowledged the importance of MDS accuracy for both payment and care planning. The facility's policy on MDS error correction outlines procedures for correcting both minor and major errors, depending on the impact on the resident's clinical status and care plan.