Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for two residents. For one resident with schizoaffective disorder, bipolar type, physician orders indicated a monthly intramuscular injection of Haloperidol, an antipsychotic medication, which was administered as ordered in June and July. However, the quarterly MDS assessment did not reflect the use of antipsychotic medications during the look-back period. For another resident with obesity, physician orders specified weekly subcutaneous injections of semaglutide for weight loss, which were administered as ordered. The quarterly MDS assessment for this resident incorrectly documented the administration of insulin, despite no physician orders or evidence of insulin administration. Interviews with the MDS coordinator confirmed the inaccuracies in the MDS assessments for both residents. The assessments in question were completed by another MDS nurse, who was unavailable for interview. The facility administrator was unaware of the reasons for the incorrect coding and stated an expectation for all MDS assessments to be accurate.