Inaccurate MDS Assessment Coding for Medication Use
Penalty
No penalty information released
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Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was completed accurately for one resident. Specifically, the Annual MDS assessment documented that the resident, who was severely cognitively impaired, was taking an antipsychotic medication. However, a review of the resident's electronic health record, including physician orders and the medication administration record, showed that the resident was not prescribed nor taking any antipsychotic medication. The MDS nurse acknowledged that the MDS was miscoded after reviewing the records, and the Director of Nursing confirmed the expectation that the MDS should accurately reflect the medications taken by residents.