F0641

D

Inaccurate MDS Coding for IV Access and Hypoglycemic Medication Use

Silver Spring, Maryland Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that MDS assessments accurately reflected residents’ clinical status and physician-documented care for two residents. For one resident with high-grade papillary urothelial carcinoma status post chemoradiation, chronic kidney disease stage 4, and chronic obstructive pulmonary disease, both the admission and quarterly MDS assessments documented that the resident had no IV access. However, hospital discharge records, the facility history and physical, and multiple provider progress notes consistently documented the presence of a Port-a-catheter/central IV line in the right upper chest used for chemotherapy. A GNA and a staff nurse both recalled that this resident was admitted with an IV line/port in the right chest, confirming that IV access was present despite being coded as absent on the MDS.

For another resident admitted with diabetes, COPD, obstructive and reflux uropathy, chronic kidney disease, hypertension, and dementia, a significant change MDS assessment indicated that the resident was taking a hypoglycemic (including insulin) medication during the look-back period. Physician orders showed that the resident’s Glipizide ER 5 mg daily was placed on hold due to lethargy and later discontinued due to poor oral intake and risk of hypoglycemia. The MAR for the same period showed that Glipizide ER was on hold and not administered from early to mid-month, indicating that the medication was not given during the MDS look-back period. Despite this, the MDS was coded as if the hypoglycemic medication had been administered. The MDS nurse and the Administrator both acknowledged that the MDS should accurately reflect the medical record and plan of care, but the assessments for these two residents did not do so.