Inaccurate MDS Coding for Medication Use and Falls
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents, resulting in incorrect coding of antidepressant use and falls. For one resident with diagnoses including Alzheimer’s disease and major depressive disorder, the quarterly MDS dated 3/30/26 indicated the resident received an antidepressant during the 7‑day lookback period, but the clinical record contained no active physician order for an antidepressant and the electronic Medication Administration Record showed no administration of an antidepressant during that time. For another resident with dementia, the quarterly MDS dated 3/30/26 coded one fall with no injury since the prior assessment on 12/29/25, yet the clinical record contained no documentation of a fall during that interval, and the Administrator confirmed the resident did not fall in that period. During interviews, the Regional Clinical Nurse stated that both MDS assessments dated 3/30/26 for these residents were wrong because the MDS Coordinator looked at the wrong dates for the fall and antidepressant, while the Administrator stated that the facility followed Resident Assessment Instrument (RAI) guidelines to code MDS assessments.
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