Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the medication status of two residents. According to the RAI User's Manual, only anticoagulant medications such as warfarin or heparin should be coded under Section N0415E1, and antiplatelet medications like aspirin should not be included. However, for two residents, the MDS assessments incorrectly indicated that they had received anticoagulant medications during the 7-day look-back period. Review of the clinical records for both residents showed physician orders for aspirin, an antiplatelet medication, but no orders for anticoagulant medications. Staff interviews confirmed that the MDS assessments were incorrectly coded, as staff had been instructed to count aspirin as an anticoagulant when used for DVT prophylaxis. This resulted in inaccurate documentation of the residents' medication use in their assessments.