Inaccurate MDS Assessments for Medication Classification and Weight Loss
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS quarterly assessment incorrectly coded Trazodone, a medication prescribed for insomnia, as a hypnotic under Section N0415, when it should have been classified as an antidepressant based on its drug class, not its use. The MDS nurse acknowledged the error, noting that the medication coding should reflect the drug classification, not the indication for which it was prescribed. This resulted in inaccurate data being transmitted to CMS. For another resident, the MDS assessment inaccurately indicated significant weight loss under Section K0300, coding 'Yes' for significant weight loss when the resident's documented weight changes did not meet the criteria of 5% loss in one month or 10% in six months. The MDS nurse confirmed the error, stating that the resident's weight loss was not significant according to the MDS definitions. Both residents had cognitive impairments and required maximal assistance with daily activities, and the inaccuracies in their assessments were identified through record review and staff interviews.