Inaccurate MDS Coding for Diabetes Medication
Penalty
Summary
The facility failed to ensure the accurate coding of Section N of the Minimum Data Set (MDS) for one resident reviewed for unnecessary medications. The resident, who had a diagnosis of diabetes mellitus, was documented in the MDS as having received insulin injections twice during the assessment period. However, a review of the provider's orders and the resident's medication administration record revealed that the resident was prescribed dulaglutide, a GLP-1 receptor agonist, administered once weekly, and was not receiving insulin during the look-back period. This discrepancy was confirmed by both an LPN and the MDS coordinator, who acknowledged the inaccuracy in the MDS coding. A policy regarding MDS completion and accuracy was requested but not provided.