Inaccurate MDS Coding for High-Risk Medications
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for six residents regarding the administration of anticoagulant, antiplatelet, and hypnotic medications. According to the facility's policy and the CMS RAI Manual, the MDS must reflect all high-risk drug classes administered during the seven-day look-back period. However, review of medical records, physician orders, and medication administration records (MARs) revealed discrepancies between the medications actually administered and those coded on the MDS. Specifically, residents who received antiplatelet medications such as Plavix and Aspirin, and hypnotic medications like Temazepam (Restoril), were incorrectly coded as having received anticoagulants or not coded for hypnotics or antiplatelets as appropriate. For example, several residents had active orders and received administration of antiplatelet medications, but their MDS assessments indicated receipt of anticoagulants instead, with no documentation of anticoagulant administration. In other cases, hypnotic medications were administered but not coded on the MDS. The review of the MARs and physician orders confirmed that the medications administered did not match the MDS coding for these drug classes. This pattern was consistent across all six residents reviewed, each with varying diagnoses such as cerebral infarction, congestive heart failure, cerebrovascular disease, insomnia, and peripheral vascular disease. Interviews with facility staff, including the RN responsible for completing Section N of the MDS, confirmed that the errors were due to inaccurate coding. The RN acknowledged that information is gathered from medical records, but the assessments were not accurately reflecting the medications administered. The DON and Administrator were also aware of the inaccuracies and confirmed that there was no triple-check system in place to ensure the accuracy of MDS coding, relying instead on staff to code accurately based on their review of records.