Inaccurate MDS Coding for Fluid Intake and Antipsychotic Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident in the areas of daily fluid intake by intravenous (IV) or tube feeding and the use of antipsychotic medication. The resident, who had diagnoses including Alzheimer's disease, dementia, anorexia, and dysphagia, was documented in her quarterly MDS assessment as having received an average of 501 cc or more of fluids per day by IV or tube feeding and as having received antipsychotic medications on a routine basis during the look-back period. However, review of the resident's electronic Medication Administration Records (eMAR) for the relevant months showed that she had not received any antipsychotic medications or fluids by IV or tube feeding during that time. The MDS Coordinator confirmed, after reviewing the assessment and medical records, that the resident had not received these treatments during the look-back period and noted that a float nurse had completed the assessment. The Director of Nursing stated that data entered into the MDS should always be accurate.