Inaccurate MDS Coding of Anticoagulant Use for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the medication status of two residents. For both residents, the MDS indicated that they were receiving anticoagulant medications, such as warfarin or heparin, when in fact neither resident was prescribed or taking an anticoagulant. Instead, both residents were on low-dose aspirin therapy, which was incorrectly coded as an anticoagulant on their MDS assessments. This error was confirmed through interviews with the MDS nurse, the Regional MDS nurse, and the ADON, all of whom acknowledged that the residents should not have been marked as receiving anticoagulants. The affected residents had significant medical histories, including hemiplegia, hemiparesis, cerebral infarction, Type 2 Diabetes, hypertension, and a coagulation deficit. The physician's orders and care plans for both residents did not include any anticoagulant medications, only aspirin therapy. The MDS nurse, who was new, stated she was unsure about the correct coding, and the Regional MDS nurse confirmed the assessments were coded incorrectly. The facility's policy required accurate and comprehensive assessments, but this was not followed in these cases.