Inaccurate MDS Coding of Non-Insulin Diabetes Medication as Insulin
Penalty
Summary
The facility failed to ensure an accurate MDS assessment in the medication section for one resident with type 2 diabetes mellitus. The resident’s quarterly MDS with an ARD of 9/25/25 was coded to show that she received insulin injections on all 7 days of the look-back period. However, review of the September 2025 MAR showed that during this period she was administered liraglutide, a non-insulin injectable medication for type 2 diabetes, once daily at 8:00 AM from 9/18/25 through 9/25/25. In a telephone interview, the MDS nurse who completed the assessment stated she coded insulin injections for 7 of 7 days because the resident received daily liraglutide injections and she relied on a reference sheet she had found that listed liraglutide under insulins. In separate interviews, the DON and the Administrator acknowledged that the MDS nurse had coded the resident as receiving insulin based on the liraglutide injections and both stated that MDS assessments should be coded accurately to reflect the medications residents actually received.
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