Inaccurate Coding of Physician-Documented GDR Contraindication on MDS
Penalty
Summary
The facility failed to accurately code a physician-documented gradual dose reduction (GDR) as clinically contraindicated on the Minimum Data Set (MDS) assessment for one resident. Record review showed that the psychiatric provider documented that a dosage reduction to the resident's psychotropic regimen was likely to impair function and worsen the underlying psychiatric condition. However, the annual MDS assessment did not reflect that the physician had documented the GDR as clinically contraindicated. During interviews, the MDS nurse confirmed she completed the relevant section of the MDS and acknowledged that she incorrectly marked the GDR as not clinically contraindicated, which was an error. The administrator confirmed the expectation for MDS assessments to be accurate.