Inaccurate MDS Coding for Antipsychotic Medication
Penalty
No penalty information released
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Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's medication status. A review of the clinical record for a resident admitted with diagnoses including bipolar disorder, depression, and anxiety showed that the annual MDS assessment indicated the resident was not receiving antipsychotic medication. However, physician orders documented that the resident was prescribed Risperidone, an antipsychotic, to be administered nightly. During interviews, facility staff confirmed that the MDS was inaccurately coded and acknowledged that all residents' MDS assessments should accurately reflect the medications they receive.