Inaccurate MDS Coding of Opioid Use
Penalty
Summary
Facility staff failed to accurately code a resident’s use of opioid medication on a quarterly MDS assessment. The resident was admitted with multiple diagnoses including hypertension, CVA with left-sided residual deficit, atrial fibrillation, parainfluenza, epilepsy, type 2 DM, vascular dementia, and schizophrenia. Physician orders documented continuous use of Tramadol HCl 50 mg PO every 8 hours for pain beginning in mid-November and continuing through at least early March, with only brief discontinuation and reordering, and MAR review confirmed that staff administered Tramadol 50 mg every 8 hours for low back pain during this period. Despite this ongoing opioid administration, the quarterly MDS listed the resident as receiving an antidepressant, anticoagulant, hypoglycemic, and anticonvulsant, but did not indicate that the resident was receiving opioids for pain. During an interview, the MDS Coordinator acknowledged that the omission of the opioid on the MDS assessment was an oversight.
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