Inaccurate MDS Assessment for Antiplatelet Medication Administration
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident in relation to unnecessary medications. According to the report, the MDS assessment indicated that the resident received antiplatelet medication during the 7-day look-back period. However, a review of the Medication Administration Record (MAR) showed that the resident's order for Aspirin, an antiplatelet, was discontinued and the last dose was administered prior to the resident's hospitalization. The resident did not receive any antiplatelet medication during the 7-day look-back period covered by the MDS assessment. Interviews with the MDS Coordinator and the Director of Nursing (DON) confirmed that the MDS assessment was incorrectly coded, as the resident had not received antiplatelet medication during the specified period. The DON stated that it was her expectation for MDS assessments to be accurate, and acknowledged that the assessment in question was not accurate regarding the administration of antiplatelet medications. The resident involved had a medical history including atrial flutter, anxiety, dementia, hypertension, and required assistance with personal care.