Incorrect MDS Coding for Insulin Administration
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two of seventeen sampled residents, as required by federal and state regulations. Specifically, the MDS for both residents was coded to indicate that they had received insulin injections during the 7-day look back period. However, a review of the Medication Administration Records (MAR) for both residents showed no documented administrations of insulin during that time frame. Instead, the records indicated that the residents had received other injectable medications for Type 2 Diabetes—Trulicity and Ozempic—which are not classified as insulin. The Minimum Data Set Coordinator (MDSC) confirmed during an interview that the residents did not receive insulin during the assessment period and acknowledged that the MDS coding was incorrect. The coding error was attributed to the misclassification of non-insulin injectable diabetes medications as insulin in the MDS documentation. This discrepancy was identified through record review and staff interview, confirming that the facility did not follow the correct coding instructions as outlined in the Resident Assessment Instrument (RAI) Manual.