Inaccurate MDS Medication Documentation
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the prescribed medications for a resident with multiple complex diagnoses, including multiple sclerosis, major depressive disorder, anxiety, seizures, bipolar disorder, brief psychotic disorder, and psychosis. After being readmitted from an acute care hospital, the resident was prescribed several medications, including antidepressants, anticonvulsants, antipsychotics, antibiotics, and opioids. Review of the Medication Administration Report (MAR) confirmed that these medications were administered during the seven-day lookback period relevant to the MDS assessment. However, the MDS assessment completed for the resident did not accurately document all the medication classes received, specifically omitting antipsychotic, antidepressant, and opioid medications in Section N. The MDS Lead confirmed that the assessment should have included these drug classes and explained that the assessment was completed by a new MDS Coordinator. Corporate audits of MDS assessments were performed only on a random basis, and the facility's policy required comprehensive and accurate assessments using the Resident Assessment Instrument (RAI).