Inaccurate MDS Assessments for Medication and Immunization Documentation
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for four residents, as required by the Resident Assessment Instrument (RAI) User's Manual. For one resident receiving Risperdal for a chronic psychiatric illness, psychiatric consults documented that a gradual dose reduction (GDR) was clinically contraindicated, but the MDS assessment was incorrectly coded to indicate that no such documentation existed. Another resident received Tramadol, an opioid, for pain management throughout the assessment period, but the corresponding MDS section was not coded to reflect opioid administration. Similarly, a third resident received both Tramadol and Lamotrigine (an anticonvulsant) during the assessment period, but the MDS assessment failed to indicate the administration of these medications. Additionally, a resident who was offered and declined the influenza vaccine was incorrectly coded in the MDS as not having been offered the vaccine. Another resident received Lorazepam (an anti-anxiety medication) and oxycodone (an opioid) during the assessment period, but the MDS assessment did not reflect the administration of these medications. These inaccuracies were confirmed through interviews with the regional Registered Nurse Assessment Coordinator, who acknowledged the coding errors in the residents' MDS assessments.