Inaccurate MDS Coding for Medication Administration
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents. For one resident with a history of diabetes mellitus, physician orders and the Medication Administration Record confirmed the administration of gabapentin for diabetic neuropathy and metformin for diabetes. However, the resident's quarterly MDS assessment was not coded to reflect the use of an anticonvulsant or a hypoglycemic medication. The MDS nurse acknowledged the miscoding during an interview and could not provide a reason for the error. In another case, a resident with atrial fibrillation was not prescribed or administered any anticoagulant medication, as confirmed by physician orders and the Medication Administration Record. Despite this, the resident's quarterly MDS assessment was incorrectly coded as receiving an anticoagulant. The responsible MDS nurse admitted to the coding error during an interview. In both instances, the facility administrator stated an expectation for accurate completion of MDS assessments.