Inaccurate MDS Coding for Insulin Administration
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for one resident. During a quarterly MDS assessment, the resident was incorrectly documented as having received seven insulin injections during the look-back period, despite a review of physician orders and medication administration records showing no insulin was ordered or administered before or after the look-back period. The resident, who has diabetes, was instead being treated with two oral diabetic agents. The MDS coordinator confirmed that the error likely occurred when an oral diabetic medication was mistakenly coded as insulin. The facility did not have a specific MDS policy and followed the RAI manual.