F0641

D

Inaccurate MDS Coding for Ventilator Use and Insulin Administration

Keokuk, Iowa Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) quarterly assessments accurately reflected the current clinical status and treatment orders for two residents. For one resident, the MDS dated 10/16/25 documented use of an invasive mechanical ventilator under Section O (Special Treatments, Procedures, and Programs) and receipt of insulin injections on one of seven days in the look-back period under Section N (Medications – Insulin). However, the resident’s active orders as of 1/07/25 showed only a weekly Trulicity (dulaglutide) subcutaneous injection for type 2 diabetes mellitus and nightly CPAP for obstructive sleep apnea, with no orders for an invasive mechanical ventilator or insulin administration. The resident’s care plan, revised on 10/21/25, also lacked any indication of invasive mechanical ventilator use or insulin injections.

For the second resident, the MDS quarterly assessment dated 10/23/25 documented insulin injections on one of seven days in the look-back period, and the care plan included a focus area for diabetes mellitus with interventions stating that the resident received insulin injections and that staff could administer insulin and check blood sugars in various locations. Review of active orders as of 1/07/25 showed weekly Trulicity (dulaglutide) injections and daily oral Tradjenta (linagliptin) for type 2 diabetes mellitus, with no orders for insulin administration. Staff interviews confirmed that Trulicity had been incorrectly coded as insulin on the MDS for both residents and that the facility had no residents with invasive mechanical ventilators, indicating that the MDS entries did not follow the facility’s MDS Assessments policy or the RAI guidelines referenced therein.