Inaccurate MDS Documentation of Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' medication status for three out of twelve sampled residents. Specifically, quarterly and annual Minimum Data Set (MDS) assessments incorrectly documented that these residents were taking antipsychotic medications, when in fact, their medication records showed they were only prescribed medications for depression, anxiety, or insomnia, none of which were classified as antipsychotics. The medications listed included nortriptyline, Effexor, Zoloft, Welbutrin, Celexa, clonazepam, and Remeron, all of which are not antipsychotic medications. Interviews with facility staff revealed confusion and miscommunication regarding the classification of these medications. The MDS Coordinator stated that the pharmacist conducted psychotropic medication reviews and had advised marking the residents as taking antipsychotics on the MDS assessments, despite the medications not fitting that category. The DON also expressed uncertainty about why the MDS assessments indicated antipsychotic use when the residents were not actually prescribed such medications. This resulted in inaccurate documentation of the residents' medication status on official assessments.