Inaccurate MDS Medication Assessment for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the medication status of two residents. For both residents, the comprehensive MDS assessments indicated that they were receiving anticoagulant medications. However, a review of provider orders for the relevant period showed that neither resident was prescribed an anticoagulant. Instead, both residents were taking clopidogrel, which is not classified as an anticoagulant. The MDS Coordinator, a registered nurse, acknowledged during an interview that the assessments were completed incorrectly, as clopidogrel had been mistakenly marked as an anticoagulant. The residents involved had medical histories including heart complications, stroke, and brain aneurysms. The incorrect documentation in the MDS assessments resulted from not following the correct process for verifying medication types against provider orders.