Inaccurate MDS Coding for PASARR and High-Risk Drug Classes
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for several residents in the areas of Preadmission Screening and Resident Review (PASARR) and high-risk drug class usage, specifically anticoagulant, antipsychotic, and opioid medications. For one resident with high blood pressure and peripheral vascular disease, the MDS assessment incorrectly indicated anticoagulant use during the assessment period, while the Medication Administration Record (MAR) showed only aspirin was administered, not an anticoagulant. Another resident with cerebral infarction and bipolar disorder had completed a PASARR Level II assessment, but the annual MDS assessment failed to reflect this, and the quarterly MDS inaccurately coded the resident as receiving anticoagulant, antipsychotic, and opioid medications, despite the MAR showing none were administered during the relevant period. A third resident with a history of cerebrovascular accident was also incorrectly coded in the MDS as receiving anticoagulants, when only aspirin was ordered. Interviews with the MDS Coordinator revealed a misunderstanding regarding the classification of aspirin as an anticoagulant and acknowledged these coding errors. The Director of Nursing and the Administrator both stated their expectations for accurate MDS coding, but the assessments were not completed in accordance with established medication categories and PASARR evaluation status.