Inaccurate MDS Coding of Anticoagulant Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment for a resident in relation to medication use. The facility’s MDS policy, dated 11/05/2019, requires comprehensive, accurate, and standardized assessments of each resident’s functional capacity using the MDS 3.0 PDPM User’s Manual. For one resident (R2), the MDS dated 10/XX/2025 documented that the resident was receiving an anticoagulant medication. However, review of the Medication Administration Record (MAR) for the period 10/1/25–10/31/25 showed no documentation that an anticoagulant medication was administered during that time. During an interview on 1/14/2026 at 1:00 p.m., the Director of Nursing (V2) confirmed that R2’s medical record did not show that the resident was taking an anticoagulant at the time of the assessment and stated she did not recall the resident ever being on an anticoagulant. V2 acknowledged that the MDS assessment for R2 must have been coded incorrectly, demonstrating that the MDS did not accurately reflect the resident’s actual medication regimen.
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