Inaccurate MDS Coding for Weight Loss and Medication Classification
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. For one resident with diagnoses including bipolar disorder, anxiety, and chronic pain, the MDS was incorrectly coded to indicate significant weight loss in the Swallowing/Nutritional Status section, despite confirmation from the Registered Dietitian that no such weight loss had occurred. This error was identified through a review of the resident's clinical record and MDS instructions, which specify the criteria for coding weight loss. For another resident with diagnoses such as Type 2 diabetes, bipolar disorder, long-term kidney disease, and adult failure to thrive, the MDS was repeatedly coded to indicate the use of an anticoagulant in multiple assessments. However, the resident was actually receiving ticagrelor, an antiplatelet medication, not an anticoagulant. The Registered Nurse Assessment Coordinator confirmed that the MDS coding for anticoagulant use was incorrect across several quarterly and annual assessments. These inaccuracies were identified through clinical record review and staff interviews.
Plan Of Correction
Resident R13's Minimum Dataset assessment dated 4/1/25 was corrected with the removal of weight loss, and resubmitted 7/8/25. Resident R43's Minimum Dataset assessments dated 8/29/24, 11/21/24, 2/13/24, 5/8/25, and 6/3/25 were corrected to reflect the resident was receiving an antiplatelet and not an anticoagulant on 7/8/25 and resubmitted. The Utilization Review Director provided education to all staff that complete Section N and K of the Minimum Dataset Assessment. The Utilization Review Director or designee will conduct weekly audits of a minimum of 25% of the comprehensive and quarterly Minimum Dataset assessments for accurate documentation of medication classification of antiplatelet vs. anticoagulant. The Utilization Review Director or designee will conduct weekly audits of a minimum of 25% of the comprehensive and quarterly Minimum Dataset assessments for accurate documentation of weight loss. All residents' most recent Minimum Dataset assessments will be audited on Section K and N, and errors will be corrected and resubmitted. Audits will be forwarded to the Quality Assurance review monthly until 100% compliance is achieved for three consecutive months, then quarterly. Completion Date: 7/31/25