Inaccurate MDS Assessment for Medication Administration
Penalty
Summary
Facility staff failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. Specifically, the MDS dated 04/25/25 indicated that the resident had received antipsychotic medications during the 7-day look-back period, as marked in Section N0415A1. However, a review of the resident's Medication Administration Record (MAR) for the same period showed that no antipsychotic medications were administered. The resident involved had a history of stroke, dementia, insomnia, and major depressive disorder. The MDS Coordinator confirmed during an interview that the resident did not receive antipsychotic medications during the specified period and acknowledged that the MDS was incorrectly coded as if the medications had been given. This discrepancy resulted in the MDS not accurately reflecting the resident's medication administration during the assessment period.