Inaccurate MDS Medication Coding for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for medications for two residents. For one resident with bladder dysfunction and urinary retention, review of the Medication Administration Record (MAR) for a specified seven-day period showed that no antibiotic medications were administered. However, the quarterly MDS assessment for that same assessment period was coded to indicate the resident had received an antibiotic. Upon review of the MDS and MAR, the MDS Coordinator confirmed that the antibiotic entry on the MDS was incorrect and that the resident had not received an antibiotic during the assessment window. For another resident with dementia with psychotic disturbance and PTSD, physician orders directed administration of Hydroxyzine 12.5 mg twice daily for anxiety, and the MAR confirmed the medication was given as ordered throughout the month reviewed. The quarterly MDS assessment, completed by an MDS nurse, documented that the resident was receiving medications from the antianxiety drug classification and included indications for antianxiety use. During interview, the MDS nurse stated the resident was not ordered any medications classified as antianxiety drugs and acknowledged she had coded the resident as receiving antianxiety medications based on the Hydroxyzine order, being unsure of its drug class. After reviewing medication information, she confirmed Hydroxyzine is classified as an antihistamine and acknowledged that coding it as an antianxiety medication on the MDS was an error.
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