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F0641
D

Inaccurate MDS Coding for Hospice and Antipsychotic Medication

Mount Airy, North Carolina Survey Completed on 06-11-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately code Minimum Data Set (MDS) assessments for two residents in the areas of hospice care and antipsychotic medication use. For one resident with major depressive disorder and Alzheimer's disease, the medical record showed an active order and administration of quetiapine, an antipsychotic medication. However, the quarterly MDS assessment incorrectly indicated that the resident had not received any antipsychotic medication since the last assessment. The MDS nurse acknowledged marking the wrong answer in the Antipsychotic Medication Review section, stating it was a mistake. For another resident with chronic obstructive pulmonary disease who was certified for hospice care, the quarterly MDS assessment indicated the resident was receiving hospice care but did not mark that the resident had a condition or chronic disease that might result in a life expectancy of less than six months. The MDS Coordinator explained that the hospice recertification was not available at the time of the assessment and was uploaded later, which led to the incorrect coding. The Administrator confirmed that the MDS should have been coded correctly regarding life expectancy and hospice care.

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