Failure to Accurately Code MDS for Hypoglycemic Medication Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident in the area of hypoglycemic medication use. The resident was admitted with a diagnosis of Diabetes Mellitus II and had active physician orders for both long-acting and sliding scale insulin, which were administered daily as documented in the Medication Administration Record. Despite this, the resident's admission MDS assessment did not reflect the use of hypoglycemic medications, including insulin, during the required 7-day lookback period. Staff interviews confirmed that the omission was due to human oversight and that the MDS should have been coded to indicate the resident's receipt of hypoglycemic medication. The deficiency was identified through record review and staff interviews, which established that the resident received insulin as ordered but the MDS assessment failed to accurately capture this information.