Inaccurate MDS Medication Coding for Two Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents, as required by federal regulations. For one resident, physician's orders indicated the administration of Lisinopril-hydrochlorothiazide, a combination antihypertensive and diuretic medication, every morning during the assessment period. However, the corresponding MDS assessment did not reflect that a diuretic was administered during the seven-day look-back period. For another resident, physician's orders and the Medication Administration Record (MAR) showed that Dilantin, an anticonvulsant, was given every morning and at bedtime throughout the assessment period, but the MDS assessment failed to indicate that an anticonvulsant was received during the same timeframe. These discrepancies were confirmed through a review of clinical records, the RAI User's Manual, and staff interviews, including confirmation by the Director of Nursing. The inaccurate coding in the MDS assessments did not accurately reflect the residents' medication administration as documented in the MAR and physician's orders, resulting in noncompliance with regulatory requirements for assessment accuracy.
Plan Of Correction
A Modification Request to correct the erroneous coding for Section N0415G1 for Resident 1 for the Annual Minimum Data Set Assessment dated May 24, 2025 was completed and submitted on July 15, 2025. A Modification Request to correct the erroneous coding for Section N0415K1 for Resident 25 for the Significant Change Minimum Data Set Assessment dated April 22, 2025 was completed and submitted on July 2, 2025. Residents who receive diuretic medications have the ability to be affected by this alleged deficient practice. A whole house audit of recently completed Minimum Data Set Assessments was completed by the Director of Nursing/designee to ensure residents receiving diuretic medications were coded correctly on completed assessments. Residents who receive anticonvulsant medications have the ability to be affected by this alleged deficient practice. A whole house audit of recently completed Minimum Data Set Assessments was completed by the Director of Nursing/designee to ensure residents receiving anticonvulsant medications were coded correctly on completed assessments. The Director of Nursing reviewed the coding instructions for Section N0415G1 in the Resident Assessment Instrument Manual with the Registered Nurse Assessment Coordinator and the Licensed Practical Nurse Assessment Coordinator. The Director of Nursing reviewed the coding instructions for Section N0415K1 in the Resident Assessment Instrument Manual with the Registered Nurse Assessment Coordinator and the Licensed Practical Nurse Assessment Coordinator. Audits will be performed by the Director of Nursing/designee weekly times four weeks then monthly times two months to ensure any resident receiving diuretic medications is coded correctly. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted. Audits will be performed by the Director of Nursing/designee weekly times four weeks then monthly times two months to ensure any resident receiving anticonvulsant medications is coded correctly. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.