Inaccurate MDS Medication Assessment for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the medication status of two residents. For both residents, the MDS assessments incorrectly indicated the use of anticoagulant medications, when in fact, physician orders and care plans showed that they were prescribed antiplatelet medications (aspirin and clopidogrel) and not anticoagulants. The care plans for both residents specifically addressed antiplatelet therapy and related interventions, and there were no orders for anticoagulant medications in their records. Interviews with facility staff, including the MDS Coordinator, ADON, DON, and Administrator, confirmed that the MDS assessments were marked incorrectly regarding anticoagulant use. The MDS Coordinator acknowledged the error and was unsure how the incorrect information was entered. The facility's policy required the interdisciplinary team to utilize the Resident Assessment Instrument (RAI) for all MDS processes, but this was not followed accurately in these cases.