Inaccurate MDS Coding for Discharge Status and Medication Administration
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, resulting in deficiencies related to discharge status and medication administration. For one resident admitted with a fractured femur, the clinical record and discharge documentation indicated the resident was discharged home, but the Discharge MDS was incorrectly coded as a discharge to a short-term general hospital. The Social Services Director acknowledged making an incorrect entry, and both the Registered Nurse and Director of Nursing confirmed that it is the responsibility of the discipline completing each section of the MDS to ensure accuracy before submission. For another resident admitted with a seizure diagnosis, the Quarterly MDS indicated the resident was taking an anticoagulant, but a review of physician's orders and the Medication Administration Record for the relevant period showed no anticoagulant was ordered or administered. The error was confirmed by a Registered Nurse after reviewing the records, and the Administrator acknowledged the discrepancies in MDS coding for both discharge status and medication administration. These findings were based on record reviews, staff interviews, and facility policy review, and represent a pattern of deficiency as the same tag was cited on the previous annual recertification survey.