Failure to Accurately Code Anticonvulsant Medication in MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident by not properly coding Depakote, an anticonvulsant medication, under Section N0415 (High-Risk Drug Classes) as required. The resident in question had diagnoses including paranoid schizophrenia, bipolar disorder, and anxiety disorder, and was prescribed Depakote for bipolar disorder. Despite the medication's pharmacological classification as an anticonvulsant, it was not marked as such in the MDS assessment. The Minimum Data Set Nurse (MDSN) acknowledged during interview and record review that Depakote should have been coded as an anticonvulsant regardless of the reason for its prescription, as per the Resident Assessment Instrument (RAI) manual. The MDSN admitted to not coding Depakote as an anticonvulsant in previous assessments and stated that this error was not previously flagged. The facility's policy and procedure on conducting accurate resident assessments requires that all assessments reflect the resident's status at the time and be completed by qualified staff. The inaccurate MDS assessment resulted in incorrect data being transmitted to CMS, specifically related to medication classification and care screening.