Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to ensure that a resident's status was accurately identified on the Minimum Data Set (MDS) assessment. Specifically, a resident with diagnoses including peripheral vascular disease, chronic atrial fibrillation, edema, and chronic venous hypertension with ulcers and inflammation was receiving warfarin, an anticoagulant, as documented in physician orders. However, the quarterly MDS assessment did not indicate that the resident was receiving anticoagulant medication, despite other medications being correctly documented. The director of nursing confirmed that the MDS was coded incorrectly, and the MDS coordinator acknowledged that the omission was an oversight, as the resident had consistently been on warfarin during the assessment period. A policy on MDS coding was requested but not provided.