Inaccurate MDS Coding for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the use of antipsychotic medication for a resident. Record review showed that the resident, who had diagnoses including encephalopathy, diabetes mellitus type 2, and depression, was prescribed Seroquel (an antipsychotic) in two different dosages for psychosis-related behaviors. However, the MDS assessment did not indicate that the resident was receiving any antipsychotic medication. This discrepancy was confirmed during interviews with both the MDS Director and the Director of Nursing, who acknowledged that the MDS was not coded accurately. The inaccurate MDS assessment meant that the resident's use of antipsychotic medication was not properly documented, which could affect the resident's plan of care and the delivery of services. The facility's policy requires comprehensive and accurate assessments at designated intervals, and all staff completing any portion of the MDS must attest to the accuracy of the information. The failure to accurately code the MDS assessment was identified through both record review and staff interviews.