Inaccurate MDS Coding of Anticoagulant Use
Penalty
Summary
The facility failed to ensure the accuracy of a resident assessment for one resident when the quarterly MDS dated February 2, 2025, indicated in section N0415 (High Risk Drug Classes) that the resident was receiving an anticoagulant. Clinical record review, including the physician’s orders and the Medication Administration Record for the assessment lookback period, showed no evidence that the resident had been ordered or administered an anticoagulant during that time. In an interview on February 27, 2025, at 12:10 p.m., licensed staff member E3 confirmed that the MDS assessment had been coded inaccurately, resulting in an assessment that did not accurately reflect the resident’s actual medication regimen. This deficiency was cited under 42 CFR 483.20 related to the accuracy of assessments and 28 Pa. Code 211.5(f) regarding clinical records, and had been previously cited on multiple prior survey dates.
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