Inaccurate MDS Assessment Due to Incorrect Medication Coding
Penalty
Summary
The facility failed to accurately document and submit a correct Minimum Data Set (MDS) assessment for one resident. The MDS assessment for this resident indicated a Brief Interview of Mental Status (BIMS) score of 13, reflecting intact cognition, and listed diagnoses of hypertension, diabetes, and obesity. The assessment also reported that the resident received insulin injections daily during the lookback period. However, a review of the clinical record revealed no documentation of insulin administration or any injections during that period. Interviews with the MDS coordinator confirmed that the previous coordinator had incorrectly coded the medication administration, and it was also noted that the facility did not have a policy in place for ensuring MDS accuracy and completion, relying instead on the RAI Manual.