Inaccurate MDS Coding for Dialysis and Medications
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in the areas of dialysis and medication administration. For one resident who was admitted with a physician's order to receive dialysis three times weekly, documentation in the Medication Administration Record (MAR) confirmed that dialysis was provided on specific dates. However, the resident's quarterly MDS assessment was not coded to reflect that dialysis was received during the assessment period. The MDS Coordinator acknowledged the error, stating that although her worksheet indicated the resident received dialysis, she failed to code it correctly in the MDS. In another case, a resident's physician's orders and MAR showed that the resident was prescribed and received an antiplatelet medication (Plavix) daily, with no orders or documentation for insulin administration. Despite this, the resident's 5-day MDS assessment was incorrectly coded as receiving an insulin injection and not coded for the antiplatelet medication. The MDS Coordinator confirmed these were errors, noting that her worksheet indicated the intent to code the antiplatelet medication, but it was missed. Both the Administrator and Director of Nursing confirmed that MDS assessments should accurately reflect the care and medications provided.