Inaccurate MDS Coding of Insulin Use for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents when insulin use was incorrectly documented. For one resident, an MDS dated 12/15/25 indicated in Section N that the resident received insulin, while the Physician Order Sheet (POS) for December 2025 contained no insulin orders. A second resident’s MDS dated 11/13/25 also documented insulin administration in Section N, but the December 2025 POS did not include any insulin orders. Similarly, a third resident’s MDS dated 10/2/25 recorded insulin use in Section N, yet the December 2025 POS showed no insulin orders for that resident. On 1/28/2026 at 11:28 AM, the Regional Clinical Nurse (V27) confirmed that these three MDS assessments were coded incorrectly, with insulin documented for each resident despite the fact that none of them actually received insulin according to their physician orders.
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