Inaccurate MDS Coding for Medication Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in the areas of anticonvulsant and anticoagulant medication use. For one resident with a history of convulsions, stroke, and nontraumatic intracranial hemorrhage, the MDS assessment did not reflect the use of an anticonvulsant medication, despite a physician's order and administration of levetiracetam. Instead, the assessment incorrectly indicated the use of an anticoagulant medication, although there were no physician orders or administration records for such medication. The MDS Nurse acknowledged the error, stating it was likely due to mistakenly selecting the wrong medication category during assessment completion. For another resident with a history of stroke, the MDS assessment was also inaccurately coded to indicate the use of an anticoagulant medication, despite the absence of any physician orders or administration records for anticoagulants during the relevant period. The MDS Nurse confirmed this was an error in coding. In both cases, the responsibility for accurate MDS coding was attributed to the MDS Nurse by the facility Administrator.