Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the accurate coding of a Minimum Data Set (MDS) assessment for one resident. A quarterly MDS assessment indicated that the resident received an anticoagulant medication during the look-back period. However, a review of the Medication Administration Record (MAR) for the same period showed no documentation that the resident received an anticoagulant. The Director of Nursing Services (DNS) confirmed that the resident was not on an anticoagulant during the look-back period, as it had been discontinued prior to that time. The MDS assessment was therefore coded in error, contrary to the requirements outlined in the CMS Resident Assessment Instrument (RAI) manual, which specifies that medication administration records should be reviewed for the 7-day look-back period to ensure accurate coding.