Inaccurate MDS Coding of Medications for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, resulting in incorrect documentation of medications received. For one resident, the admission MDS indicated receipt of an insulin injection, but the physician order report showed the resident was only receiving Ozempic, a GLP-1 receptor agonist, which should not be classified as insulin or a high-risk hypoglycemic medication according to the Resident Assessment Instrument (RAI) Manual. The MDS coordinator confirmed the resident was not receiving insulin and expressed uncertainty about how to code Ozempic, indicating a lack of reference to the RAI Manual at the time of coding. For another resident, the admission MDS documented receipt of both an antiplatelet and an anticoagulant medication, but the physician order report only listed aspirin, which should be coded solely as an antiplatelet. The MDS coordinator acknowledged the error, confirming the resident was not on an anticoagulant. The director of nursing agreed that the MDS coding for both residents was inaccurate. Additionally, a facility policy on MDS was requested but not provided.