Inaccurate MDS Coding for Medication Administration
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident regarding the administration of anticonvulsant and anticoagulant medications. The resident, who had diagnoses including diabetes and a seizure disorder, was prescribed and received anticonvulsant medications (lamotrigine and pregabalin) as documented in the electronic medical record and Medication Administration Record. However, the MDS assessment did not indicate that the resident received anticonvulsant medications during the 7-day look back period. Additionally, the MDS assessment incorrectly reported that the resident received an anticoagulant medication, despite no evidence in the records that such medication was administered during that period. These inaccuracies were confirmed during interviews with the facility's MDS Coordinator, who acknowledged the errors after reviewing the resident's records and MDS assessment. The facility's Administrator also stated that MDS assessments are expected to be coded accurately. The deficiency was identified through staff interviews and record reviews, which revealed the discrepancies between the resident's actual medication administration and what was documented in the MDS assessment.