Inaccurate MDS Medication Coding for Multiple Residents
Penalty
Summary
Casselman Healthcare and Rehabilitation Center was found to be noncompliant with federal and state regulations regarding the accuracy of Minimum Data Set (MDS) assessments for three residents. Surveyors determined that the facility failed to accurately complete MDS assessments as required by the Resident Assessment Instrument (RAI) User's Manual. Specifically, for one resident receiving Gabapentin for diabetic neuropathy and another receiving Pregabalin for neuropathy, the assessments did not indicate that these residents had received anticonvulsant medications during the seven-day assessment period, despite documentation in the Medication Administration Records confirming administration of these drugs. Additionally, a third resident who was prescribed and received Silvadene (an antibiotic cream) for wound care was not coded as having received an antibiotic in the corresponding MDS assessment. These inaccuracies were confirmed through review of physician orders, medication and treatment administration records, and staff interviews, including confirmation by the Director of Nursing. The failure to accurately code the administration of anticonvulsant and antibiotic medications in the MDS assessments resulted in the facility not meeting the requirements for accurate resident assessments as outlined in 42 CFR Part 483 and the Pennsylvania Long Term Care Licensure Regulations.
Plan Of Correction
The MDS assessments (Minimum Data Set, a standardized assessment tool) for R3, R38, and R53 were modified per Resident Assessment Instrument (RAI) manual requirements. The Nursing Home Administrator re-educated the Director of Nursing and MDS Coordinator on the need to ensure coding for Gabapentin, Pregabalin, and Silvadene are accurate on the MDS. Whole house audit was completed by the MDS Coordinator to identify any other residents who may have orders for Gabapentin, Pregabalin, or Silvadene that were miscoded. Any identified MDS coding errors were fixed and the MDS resubmitted per RAI manual requirements. The Interdisciplinary team will review new orders daily (Monday through Friday) to identify any Gabapentin, Pregabalin, and Silvadene to note the need to correctly code the MDS when scheduled to be completed. The audit outcomes will be presented to the Quality Assurance Committee for review and recommendations.