Inaccurate MDS Medication Coding for Psychotropic and Antiplatelet Drugs
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident when required medication use was not correctly documented. Record review showed that this resident had multiple active physician orders, including Zoloft 100 mg daily for depression, Depakote Sprinkles 125 mg two capsules twice daily for dementia with behaviors, Gabapentin 300 mg twice daily for anxiety, Aspirin 81 mg daily for prophylactic measures related to a history of stroke, and Clopidogrel 75 mg daily for prophylactic measures related to a history of stroke. These orders established that the resident was receiving antidepressant, anticonvulsant, and antiplatelet medications during the assessment period. Despite these active medication orders, the resident’s MDS, in Section N – Medications, indicated that the resident did not take antidepressant, anticonvulsant, or antiplatelet medications. During an interview, the MDS coordinator confirmed that the assessment for this resident was inaccurate and acknowledged that it should have reflected the use of antidepressant, anticonvulsant, and antiplatelet medications but did not.
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