Inaccurate Coding of Resident Medication Status in MDS Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' medication status for three residents. For one resident with cerebral infarction and paraplegia, the quarterly MDS assessment was coded as if the resident was receiving anticoagulant medication, but a review of physician orders showed no such medication had been ordered. For another resident with generalized anxiety disorder and depression, the Significant Change MDS assessment incorrectly documented that the resident was not receiving antianxiety medication, despite the Medication Administration Record showing administration during the assessment period. Additionally, the same resident was documented as receiving anticonvulsant medication on a subsequent MDS, but there was no evidence of administration in the corresponding records. A third resident, diagnosed with Parkinson's Disease and restless leg syndrome, had an admission MDS assessment indicating no anticonvulsant medication was received, while the Medication Administration Record showed that such medication was administered during the assessment period. In each case, staff interviews confirmed that the MDS assessments were coded incorrectly and did not accurately reflect the residents' medication status during the assessment reference periods.