Inaccurate MDS Documentation of Medication Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the medication usage for three residents. For two residents with type 2 diabetes, the MDS indicated that they received insulin during the assessment period, when in fact, their Medication Administration Records (MAR) showed they were only receiving Ozempic, a hypoglycemic medication that is not insulin. The MDS Coordinator initially believed Ozempic was an insulin, but upon review, acknowledged the error and confirmed that neither resident was receiving insulin as documented in the MDS. Additionally, for a resident with a history of stroke, the MDS indicated use of an anticoagulant medication, while the MAR showed the resident was prescribed clopidogrel bisulfate, an antiplatelet medication, not an anticoagulant. The MDS Coordinator confirmed this was a data entry error. The Administrator stated there was no specific policy for MDS accuracy, and that the facility followed the guidance in the Resident Assessment Instrument (RAI) Manual.