Failure to Accurately Code Insulin and Hypoglycemic Medication on MDS Assessment
Penalty
Summary
The facility failed to accurately code medications on the Minimum Data Set (MDS) assessment for one resident. Specifically, the resident's Quarterly MDS did not reflect the administration of insulin or other hypoglycemic medications during the 7-day look-back period, despite documentation in the Medication Administration Record and physician orders indicating that the resident received daily insulin injections and oral metformin for type 2 diabetes mellitus. The relevant MDS sections (N0300, N0350, and N0410) were either marked as zero or 'No' for injections and hypoglycemic medication use, which was inconsistent with the resident's actual medication regimen. Interview with the staff member responsible for completing the MDS assessments revealed uncertainty regarding why insulin or hypoglycemic medications were not marked for this resident. The facility's policy required the use of the current RAI (MDS 3.0) and accurate inclusion of medications as per the RAI Manual, but this was not followed in this instance. The deficiency was identified through review of the resident's records and staff interview.