Inaccurate MDS Coding of Anticoagulant Medication
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident regarding the use of anticoagulant medication. According to the facility's policy and the Resident Assessment Instrument (RAI) Manual, antiplatelet medications such as aspirin should not be coded as anticoagulants in Section N0415 of the MDS. A review of the resident's records showed that the only relevant medication order was for aspirin, prescribed for hypertension, and there were no active orders for any anticoagulant medication during the MDS lookback period. Despite this, the resident's quarterly MDS assessment was coded to indicate receipt of an anticoagulant. During interviews, a registered nurse confirmed the error, stating that aspirin had been incorrectly coded as an anticoagulant instead of an antiplatelet. The administrator and director of nursing both acknowledged that MDS assessments are expected to be coded accurately to reflect each resident's actual condition and treatment.