Failure to Accurately Code Antipsychotic Use on MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to accurately document a resident’s antipsychotic medication use on an annual Minimum Data Set (MDS) assessment. Resident D had diagnoses including delusional disorder and anxiety. Physician orders revised in early September indicated the resident was prescribed risperidone 0.25 mg twice daily for delusional disorder. Medication Administration Records for January and February showed the resident routinely received risperidone twice daily during the seven-day look-back period for the annual MDS assessment dated early February. Despite this documented and administered antipsychotic therapy, the MDS assessment’s medication section indicated that the resident had not received any antipsychotic medications during the look-back period. During an interview, the MDS Coordinator, who had over one year of experience at the facility and over five years of MDS experience, acknowledged that the medication section of the MDS contained an error. The CMS RAI User’s Manual requires that the MDS identify, by pharmacological category, any medication received in the last seven days, but this requirement was not met for Resident D’s antipsychotic medication use.
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