Inaccurate MDS Medication Coding for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for five residents, as required by the Resident Assessment Instrument (RAI) User's Manual. Specifically, the facility did not correctly code Section N of the MDS, which documents medications received in the seven days prior to assessment. For one resident, Gabapentin, an anticonvulsant, was administered nightly, but the corresponding section on the MDS was not coded to reflect this. Another resident, who had all medications discontinued upon starting hospice, was incorrectly coded as having received both antidepressant and anticonvulsant medications during the look-back period, despite the Medication Administration Record (MAR) showing otherwise. Additional deficiencies included a resident who received Divalproex, an anticonvulsant, nightly, but whose admission MDS did not indicate receipt of this medication. Another resident was administered Cephalexin, an antibiotic, twice daily, but the quarterly MDS did not reflect this. Lastly, a resident received Gabapentin both in the morning and evening, but the significant change MDS assessment failed to indicate the administration of this anticonvulsant. These discrepancies were confirmed by review of clinical records, MARs, and staff interviews, including confirmation from the Regional Registered Nurse Assessment Coordinator.