Failure to Accurately Code Antipsychotic Medication on MDS
Penalty
Summary
The facility failed to accurately code antipsychotic medication use on the Minimum Data Set (MDS) for one resident. The resident, who had a diagnosis of Schizoaffective Disorder and a moderately impaired cognitive status as indicated by a BIMS score of 9, was admitted with a physician's order for Abilify, an atypical antipsychotic. Despite this, the MDS assessment for the resident did not indicate the use of an antipsychotic medication during the lookback period, even though the Medication Administration Record confirmed that the medication was administered as ordered. Interviews with the LPN and RN responsible for completing and reviewing the MDS confirmed that the omission was an error. The facility's policy required accurate completion of the MDS to guide care planning, but the antipsychotic medication was not coded, contrary to the resident's documented medication orders and administration records. Both staff members acknowledged the discrepancy upon review.