Inaccurate MDS Coding for Medications, Diet, and Hearing Aid Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents in the areas of anticonvulsant medication use, prescribed diet, and use of a hearing aid. For one resident with Alzheimer's Disease and cerebrovascular disease, the MDS assessment did not reflect the administration of two anticonvulsant medications, gabapentin and divalproex sodium, despite active physician orders and documentation in the Medication Administration Record. The MDS Nurse acknowledged missing this information during the assessment process. Another resident, who was cognitively intact and had no swallowing issues, was incorrectly coded as receiving a mechanically altered diet on the MDS, even though physician orders and meal observations confirmed a regular diet with thin liquids. The Dietary Manager, responsible for this section of the MDS, admitted to making an error in coding. Additionally, a third resident with a cognitive communication deficit was not coded for hearing aid use on the MDS, despite observations and staff interviews confirming regular use of hearing aids. The MDS Nurse stated she was unaware of the resident's use of hearing aids at the time of assessment.