Inaccurate MDS Coding for Medications and Mental Illness
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for several residents, specifically regarding the use of anticoagulant medications and the identification of serious mental illness. For five residents, the MDS was incorrectly coded to indicate the use of anticoagulant medications when, in fact, the residents were prescribed Plavix (Clopidogrel), an antiplatelet medication, and not an anticoagulant. This error was confirmed through record reviews, which showed no orders for anticoagulant medications, and through staff interviews, where the MDS Coordinator acknowledged misunderstanding the classification of Plavix. The Director of Nursing also confirmed the misclassification and stated that the MDS should accurately reflect the residents' medication regimens. Additionally, the facility failed to accurately code the MDS for a resident with a serious mental illness. The MDS indicated that the resident was not considered to have a serious mental illness according to the state PASRR process, despite documentation from the PASRR office confirming the diagnosis of mental illness. The MDS Coordinator verified the coding error during an interview and agreed that the assessment should have reflected the resident's mental health status. These inaccuracies in the MDS assessments were identified through record reviews and staff interviews, demonstrating a failure to follow facility policy and CMS guidelines for accurate resident assessment.