Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents reviewed for anticoagulant use. According to the facility's policy and the CMS Resident Assessment Instrument (RAI) Manual, staff are required to correctly document medication use, specifically distinguishing between anticoagulants and antiplatelet medications. For both residents, medical record reviews showed active physician orders for antiplatelet medications such as aspirin and clopidogrel, but no orders for anticoagulant medications. Despite this, the MDS assessments for these residents were incorrectly coded to indicate anticoagulant use. The inaccuracy was confirmed during an interview with the MDS Coordinator, who acknowledged that the assessments did not align with the RAI manual's definitions. The residents involved had medical histories including cerebral palsy, epilepsy, congestive heart failure, muscle weakness, diabetes mellitus, displaced intertrochanteric fracture of the femur, gait abnormalities, and acute cystitis with hematuria. The deficiency was identified through a review of facility policy, the RAI manual, medical records, and staff interviews.