F0641

E

Inaccurate MDS Coding for Medications and Pneumococcal Vaccination

Smithfield, North Carolina Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves inaccurate coding of the Minimum Data Set (MDS) assessments for multiple residents in the areas of medications and pneumococcal vaccination status. For one resident, physician orders and the Medication Administration Record (MAR) showed Novolog insulin injections were administered on multiple days within the assessment look-back period, but the quarterly MDS was coded as receiving injections and insulin injections on only 5 of 7 days instead of 7 of 7 days; the MDS nurse later acknowledged this was an error. Another resident had an order for Dulaglutide, a non-insulin injectable medication for Type 2 diabetes, administered once during the look-back period, with no insulin orders in place, yet the quarterly MDS was coded to show both an injection and an insulin injection on 1 of 7 days; the MDS nurse stated she coded it as insulin because it was prescribed for diabetes.

A third resident had no physician orders or MAR documentation for anticoagulant medications during the January and February look-back periods, but the annual MDS was coded to indicate anticoagulant use; the responsible MDS nurse stated this was an error and confirmed the resident had not received anticoagulants during the assessment period. For another resident, the quarterly MDS indicated pneumococcal vaccination was up to date, while the medical record showed only a single historical dose of PPSV23 (Pneumovax) from 2014 with no documentation of additional pneumococcal vaccines. The MDS nurse later stated that coding the vaccine status as up to date was incorrect and that she had relied on outdated CDC guidelines when completing that assessment. The DON and the Administrator both stated that resident MDS assessments should be coded accurately.