Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for six residents, as required by the Resident Assessment Instrument (RAI) User's Manual. Specifically, the assessments did not accurately reflect the medications administered to the residents during the seven-day assessment periods. For example, residents who received antidepressants, insulin, anticonvulsants, diuretics, opioids, and antibiotics according to physician orders and Medication Administration Records (MARs) were not properly coded in the corresponding MDS sections. These discrepancies were identified through a review of clinical records, MARs, and staff interviews. The affected residents had documented orders and received medications such as Venlafaxine, Escitalopram, Keppra, Insulin Glargine, Mirtazapine, Lasix, Gabapentin, Tramadol, and Bacitracin-Polymixin B ointment. However, their MDS assessments failed to indicate the administration of these medications in the relevant sections. The Registered Nurse Assessment Coordinator confirmed that the assessments for these residents were coded incorrectly, resulting in inaccurate documentation of their care needs and treatments.