Inaccurate MDS Assessment Due to Misclassification of Injectable Medication
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected their medication administration status. Specifically, a quarterly Minimum Data Set (MDS) assessment for one resident was incorrectly coded to indicate that the resident had received an insulin injection during the look-back period. Review of the resident's medical records, including physician orders and medication administration records, showed that the resident was prescribed and received Trulicity, a non-insulin injectable medication, for Type 2 diabetes mellitus. There was no order or documentation of insulin administration for this resident during the relevant period. Interviews with the MDS LVN, Regional Care Manager, and Administrator revealed that the nursing staff was unaware that Trulicity is not classified as insulin, leading to the incorrect coding on the MDS assessment. The facility relied on the RAI manual for MDS coding guidance and did not have a separate policy addressing this issue. The error was identified through review of the resident's records and staff interviews, confirming that the assessment did not accurately reflect the resident's actual medication regimen.