Inaccurate MDS Coding of Insulin Injections for Non‑Insulin‑Treated Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment for one resident. The resident was admitted with diagnoses including a displaced intertrochanteric fracture of the left femur, pain in the right hip, and type 2 diabetes mellitus. The Admission/Medicare 5-day MDS documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact, and recorded that the resident received injections on 2 days in the 7-day look-back period, including 2 days of insulin injections under Section N0350. The resident’s care plan contained no focus area for diabetes and no mention of insulin or other diabetic medications. During interview, the resident, who was cognitively intact, stated they were not diabetic, had not received insulin at the facility or in the hospital, and had not undergone fingerstick glucose monitoring, though they acknowledged receiving injections that were not for diabetes. Further interviews and record review showed that nursing staff and MDS staff confirmed there were no orders for blood glucose checks and no insulin orders or administration for this resident. An LPN stated there were no orders to check fingerstick glucose and no insulin was given. Two MDS coordinators, who did not complete the original assessment, reviewed the hospital records, medications, and treatments over the 7-day period and confirmed the resident received two injections, identified as a flu shot and a COVID vaccine, not insulin. They acknowledged that documenting insulin injections on the MDS was an error. The DON stated the expectation that resident assessments be completed thoroughly and accurately. The MDS coordinator job description and the facility’s resident assessment policy both assign responsibility to the MDS nurse/resident assessment coordinator to ensure accuracy and completeness of the MDS and medical record, and to ensure timely and appropriate resident assessments and reviews, which was not met in this case.
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