Inaccurate Coding of Antipsychotic Medication Use on MDS
Penalty
Summary
The facility failed to accurately code the use of antipsychotic medication on Section N of the Minimum Data Set (MDS) for one resident. The resident, who had a diagnosis of schizophrenia and diabetes mellitus, was documented in the care plan and medication administration record as receiving olanzapine, an antipsychotic medication, for management of schizophrenia. However, the quarterly MDS assessment indicated that the resident had not received any antipsychotic medications since admission. During an interview, the DON confirmed that she completed the MDS and acknowledged that Section N was inaccurately coded, as it should have reflected the resident's ongoing antipsychotic medication use. The facility's policy requires accurate assessments reflective of the resident's status at the time of assessment by qualified staff.