Inaccurate MDS Coding of Psychotropic Medication Use
Penalty
Summary
The deficiency involves the facility’s failure to complete an accurate MDS assessment for a resident’s medication regimen. The resident’s EMR diagnosis list included dementia and anxiety. A Quarterly MDS documented a BIMS score of 15, indicating intact cognition, and recorded that the resident received an antipsychotic medication and did not receive an antidepressant during the observation period. However, the Psychotropic Drug Use CAA noted that the resident had received Seroquel during a past hospitalization, that the physician had decreased the Seroquel, and that an antidepressant had been ordered for anxiety. The resident’s care plan documented use of Sertraline, an antidepressant, with associated risk of suicidal thoughts and behaviors. Further record review showed a signed physician order discontinuing the antipsychotic during the previous observation period and a subsequent order for Sertraline 100 mg daily for anxiety. The MAR from early December through mid-February showed the resident received Sertraline 50 mg daily, and from mid-February through early March the resident received Sertraline 100 mg daily. During an interview, the Administrative Nurse acknowledged that the MDS had been marked in error, indicating antipsychotic use instead of antidepressant use during the observation period. This inaccurate documentation conflicted with the EMR, physician orders, MAR, and care plan, and did not align with the facility’s policy requiring accurate resident assessments by qualified staff knowledgeable about the resident and correctly documenting the resident’s status.
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