Inaccurate MDS Medication Coding for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents, resulting in incorrect documentation of their medication regimens. For one resident with diagnoses including dementia, seizure disorder, and mood disorder, the MDS assessment did not reflect the use of Depakote, an anti-convulsant medication that had been ordered and administered during the assessment period. The MDS nurse confirmed that the resident began taking Depakote prior to the MDS completion date, but the medication was not coded as an anti-convulsant in the assessment. Similarly, another resident with neuropathy and paraplegia was prescribed Neurontin, a medication classified as an anti-convulsant, which was administered consistently during the MDS look-back period. However, the MDS assessment for this resident did not indicate the use of an anti-convulsant. The MDS nurse acknowledged that Neurontin should have been coded as an anti-convulsant in the MDS, as it was administered within the relevant assessment timeframe. Both instances were identified through interviews and record reviews, where the MDS nurse confirmed the inaccuracies in the MDS assessments. Facility policy requires that staff completing any portion of the MDS certify the accuracy of their entries, but in these cases, the medication information was not accurately documented, leading to the transmission of incorrect data to CMS.