Inaccurate MDS Coding for Medications and Restraints
Penalty
Summary
Facility staff failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, as identified through record review, reference to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, and staff interviews. For one resident, the quarterly MDS indicated that an antianxiety medication was administered during the seven-day look-back period; however, the medical record did not show any such medication being given during that time. An administrative nurse confirmed that the MDS was incorrectly coded in this instance. For another resident, the admission MDS coded the use of bed rails as being used daily, but observations revealed that no bed rails were present for the resident. This discrepancy was also confirmed by an administrative nurse, who acknowledged that the MDS was not coded correctly. These inaccuracies in MDS coding do not allow for an accurate reflection of the residents' current status and needs.