Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to ensure accurate assessments for two residents during the review period. For one resident, the Minimum Data Set (MDS) assessment indicated that the resident was receiving an anticoagulant under Section N0415, but a review of physician orders showed no evidence that the resident was actually receiving this medication. This discrepancy was confirmed by the Director of Nursing. Similarly, another resident's admission MDS assessment indicated receipt of an anticoagulant under Section N0410, but the clinical record did not support this, and the Nursing Home Administrator confirmed the MDS was coded incorrectly. These findings were based on clinical record reviews and staff interviews, demonstrating that the facility did not accurately document medication administration in the MDS assessments for these two residents.