Inaccurate MDS Coding of Anticoagulant Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected the resident’s medication regimen, specifically the use of an anticoagulant. MDS instructions for section N0415E1 require that anticoagulant use be coded based on whether the resident is taking any medications in that pharmacological class during the last seven days or since admission if less than seven days. One resident was admitted with diagnoses including atrial fibrillation, peripheral vascular disease, and pain. The admission MDS, with an Assessment Reference Date (ARD) of 12/30/25, coded section N0415E for anticoagulant use as “No,” indicating that the resident was not receiving anticoagulant medication during the look-back period. However, the resident’s physician orders showed that on 12/28/25 there was an active order for Rivaroxaban 15 mg once daily, and the Medication Administration Record documented that the resident received this anticoagulant from 12/28/25 through 12/31/25. During an interview, the Social Worker confirmed that the resident had been receiving an anticoagulant since admission and that the admission MDS was coded inaccurately regarding anticoagulant use. This discrepancy between the clinical record, medication administration documentation, and the MDS coding resulted in an inaccurate assessment for this resident, in violation of applicable state regulations governing licensee responsibility and medical records documentation.
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