Inaccurate MDS Coding of Antianxiety and Anticonvulsant Medication Use
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for a resident in relation to antianxiety and anticonvulsant medication use. Record review showed that the resident had an order for lorazepam 1 mg every four hours as needed for anxiety from 07/02/25 through 07/16/25 and received a dose on 07/15/25 at 9:26 p.m. The resident was also ordered and received divalproex 125 mg daily from 07/01/25 through 07/16/25. However, the quarterly assessment dated 07/15/25 documented that the resident, who was assessed as severely impaired in cognition for daily decision making, had not received an antianxiety or anticonvulsant medication during the seven-day look-back period, despite the documented administration of both medications. An annual assessment dated 10/09/25 again showed the resident as severely impaired in cognition for daily decision making and indicated that the resident had not received an anticonvulsant during the seven-day look-back period. This conflicted with the October 2025 medication administration record, which showed the resident was ordered and received divalproex 125 mg daily and had doses administered on 10/03/25, 10/04/25, 10/05/25, 10/07/25, and 10/08/25. During interview, the MDS coordinator stated they reviewed the medication administration records when completing assessments and did not know why the lorazepam use was not accurately coded. The MDS coordinator further explained that because the resident did not have a diagnosis of seizures, they did not code divalproex as an anticonvulsant received during the seven-day look-back periods for either the quarterly or annual assessments.
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