Inaccurate MDS Coding for Medications and Discharge Status
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete Minimum Data Set (MDS) assessments for two residents, despite having clear clinical documentation to support correct coding. For one resident with atrial fibrillation, the medical record showed an active physician order for the anticoagulant Xarelto and a current care plan problem for anticoagulant therapy. However, the admission and Medicare 5-Day MDS assessments, specifically Section N – Medications, did not reflect that the resident was taking an anticoagulant. This discrepancy was identified during surveyor review of the resident’s medical record and comparison of the MDS with the physician orders and care plan. For another resident, review of a closed medical record showed that progress notes documented a discharge to the hospital on a specific date. In contrast, the Discharge – return not anticipated MDS assessment coded that the resident was discharged home under the care of an organized home health service organization. During an interview, the LNHA confirmed that the resident had in fact been discharged to the hospital, not home with home health services. These inconsistencies between the MDS assessments and the residents’ actual medication regimen and discharge destination demonstrate that the facility did not ensure accurate completion of MDS assessments for the residents reviewed.
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