Inaccurate MDS Coding for Antibiotic Use
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for one resident when the MDS was incorrectly coded to indicate that the resident had received antibiotics, despite no physician's orders or documentation supporting antibiotic administration. The resident in question was admitted with diagnoses including peripheral vascular disease and stiffness in both ankles. A review of the resident's admission record and physician's orders revealed no evidence of antibiotic use during the assessment period. During interviews and record reviews, the MDS nurse confirmed that the resident's MDS Section N was inaccurately coded to reflect antibiotic use, acknowledging this as an oversight and a coding discrepancy. The nurse further recognized the importance of MDS accuracy for care planning. The error was identified during a review of the MDS and supporting documentation, which did not align with the information entered into the assessment tool.