Inaccurate MDS Assessment for Pain Medication Administration
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident. A resident with a history of metabolic encephalopathy, cerebral infarction, memory deficit, and hemiplegia was admitted to the facility and had a physician's order for scheduled Tylenol for pain management. During an interview, the resident reported experiencing pain from a pressure ulcer and confirmed receiving pain medication, which was supported by physician orders. However, review of the resident's quarterly MDS assessment showed that it was incorrectly coded to indicate that the resident did not receive any scheduled pain medications during the look-back period. Staff responsible for completing the MDS assessment confirmed during interviews that the resident did receive pain medication and acknowledged the error in coding.