Inaccurate MDS Coding of Scheduled Pain and Anticonvulsant Medications
Penalty
Summary
The facility failed to ensure accurate completion of the federally mandated MDS assessments for two residents, resulting in discrepancies between physician orders and the information recorded on the MDS. For one resident, record review showed a physician’s order dated 08/13/25 for Aspirin EC 81 mg by mouth in the morning for analgesia, yet the resident’s quarterly MDS indicated that the resident did not receive scheduled pain medications; during interview, the MDS Coordinator confirmed this quarterly MDS was inaccurate because the resident does take Aspirin regularly for pain. For another resident, record review showed a physician’s order dated 09/22/23 for Depakote 250 mg by mouth three times daily for major depressive disorder, but the quarterly MDS documented that the resident did not take anticonvulsant medication; the MDS Coordinator confirmed that Depakote is an anticonvulsant and that this quarterly MDS was inaccurate. These findings demonstrate that the facility did not accurately code the residents’ medication regimens on their quarterly MDS assessments, despite existing physician orders and the MDS Coordinator’s acknowledgment that the assessments were incorrect.
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