Inaccurate MDS Coding of Medications for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the medications received by three residents during the required observation period. For one resident with a history of stroke and major depressive disorder, the MDS was incorrectly coded to show receipt of an anticoagulant and antidepressant, while the resident actually received an antiplatelet medication (clopidogrel) and did not receive the prescribed antidepressant (Lexapro) during the look-back period. The MDS Coordinator was uncertain about the correct classification of clopidogrel and relied on the medication order's wording, leading to the error. Additionally, the MDS did not reflect the missed doses of the antidepressant, as documented in the Medication Administration Record (MAR) and progress notes. Another resident with a history of transient ischemic attack and stroke was also incorrectly coded on the MDS as receiving an anticoagulant instead of an antiplatelet, due to similar confusion over medication classification. A third resident with gastroparesis was coded as not receiving antibiotics, despite daily administration of erythromycin as documented in the MAR. These inaccuracies were confirmed through interviews with the MDS Coordinator, who acknowledged the errors and the need for correction. The facility's policy requires that the MDS accurately reflect the resident's status during the observation period, which was not met in these cases.