Inaccurate MDS Assessments Due to Medication and Diagnosis Coding Errors
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for four out of twenty-three residents reviewed. Specifically, the MDS assessments incorrectly documented that certain residents were taking anticoagulant medications when, according to the electronic health records and physician orders, they were actually prescribed antiplatelet medications such as Clopidogrel (Plavix), which should not be classified as anticoagulants. Additionally, there were inaccuracies in coding active diagnoses, such as viral hepatitis, and in documenting PASRR (Pre-admission Screening and Resident Review) status for residents with mental health diagnoses. These errors were identified through clinical record review, staff interviews, and comparison with the Resident Assessment Instrument (RAI) Manual guidelines. The MDS Coordinator, who had been in the role since December, reported using the RAI Manual, staff input, and a medication classification list to complete assessments but demonstrated a lack of understanding regarding the correct classification of medications and the criteria for coding active diagnoses. For example, the coordinator incorrectly coded antiplatelet medications as anticoagulants and was uncertain about the look-back period for active diagnoses such as viral hepatitis. The facility's documentation practices did not align with the requirements outlined in the RAI Manual, leading to inaccurate MDS assessments for multiple residents with complex medical histories, including those with coronary artery disease, cerebrovascular accident, quadriplegia, and mental health conditions.