F0641

E

Inaccurate MDS Coding for Medications, Falls, Behaviors, and Treatments

Dundalk, Maryland Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, resulting in omissions and inaccuracies in several MDS sections. For one resident receiving Gabapentin every eight hours for neuropathy, the anticonvulsant was not captured in Section N0415 (High-Risk Drug Classes) on two separate MDS assessments. Another resident experienced a documented fall, noted in the medical record as being found on the floor in a sitting position, but this fall was not coded in Section J1800 (any falls since admission/entry or prior assessment). A third resident had hypoglycemic medication use coded in Section N0415, despite the November MAR showing no hypoglycemic medications administered during that period.

Additional inaccuracies were identified for a resident who received Lorazepam, an antianxiety medication, which was not captured in Section N0415 on a discharge MDS, and whose use of oxygen via nasal cannula was not coded in Section O (Special Treatments, Procedures, and Programs). The same resident was incorrectly coded in Section O as receiving hospice services and in Section J1400 as having a condition with a life expectancy of less than six months, despite no documentation supporting hospice services or such a prognosis. Another resident with documented aggressive and combative behavior, including agitation, psychosis, throwing objects at staff, and destroying property, was coded as having no physical or verbal behavioral symptoms in Section E0200. This resident was also receiving Gabapentin three times per day per the MAR, but the anticonvulsant was not captured in Section N0415. The MDS Coordinator confirmed these errors and noted that other staff had been filling in on MDS assessments during the primary coordinator’s leave.