Inaccurate MDS Coding for Mental Status and Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected three residents’ clinical status and medication use. For one resident with major depressive disorder and dementia, the annual MDS coded antipsychotic medication use in Section N0415 during the 7‑day look‑back period, but review of the clinical record showed no evidence that any antipsychotic medications had been administered during that time. For a second resident with major depressive disorder and anxiety disorder, the admission comprehensive MDS coded the resident as comatose and in a persistent vegetative state with no discernible consciousness in Section B0100, while the admission nursing assessment documented that the resident was alert and oriented to person, place, and time. For a third resident with dementia and anxiety disorder, physician orders and the medication administration record showed scheduled administration of Buspirone every eight hours and Xanax every 12 hours for anxiety/behaviors during the MDS look‑back period. However, the quarterly MDS coded that resident as not receiving antianxiety medications in the 7‑day look‑back period. Staff interviews with the MDS Coordinator and facility leadership confirmed that these MDS assessments had been coded incorrectly, and the Nursing Home Administrator and DON stated that their expectation was that MDS reports be coded accurately.
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