Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately completed for two residents regarding their receipt of antianxiety and antiplatelet medications. For one resident with diagnoses including schizoaffective disorder, general anxiety disorder, and dementia with behavioral disturbance, multiple quarterly MDS assessments indicated that the resident had not received any antianxiety medications. However, the care plan and physician's orders documented ongoing administration of clonazepam, an antianxiety medication, which was also confirmed by the Medication Administration Record (MAR). The MDS Coordinator acknowledged that the medication had been incorrectly coded as an anticonvulsant due to the classification in the computer charting system. For another resident with a history of stroke, congestive heart failure, and chronic kidney disease, the admission MDS assessment indicated no receipt of antiplatelet medications in the past seven days. Contrarily, the physician's order summary and MAR showed that the resident had been receiving ticagrelor, an antiplatelet medication, twice daily. The MDS Coordinator confirmed that the MDS assessment was incorrect and required modification.