Incorrect MDS Coding for Hypoglycemic Medication Usage
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments regarding hypoglycemic medication usage for one resident. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) Manual, the hypoglycemic medication box should be checked only if the resident received such medication during the 7-day observation period. Record reviews showed that the resident's MDS assessments on two separate occasions indicated the use of hypoglycemic medication, despite the Medication Administration Records for the corresponding periods showing no evidence that the resident had received any hypoglycemic medications. This discrepancy was confirmed during an interview with a registered nurse, who acknowledged that the MDS assessments were incorrectly coded. The resident in question had not been administered hypoglycemic medication during the lookback periods for either MDS assessment, yet the documentation inaccurately reflected otherwise. The facility census at the time was 35 residents, and this error was identified for one of five sampled residents.