Failure to Accurately Code MDS for Antipsychotic GDR Contraindication
Penalty
Summary
The facility failed to accurately code the MDS assessment for one resident by omitting physician-documented information that a gradual dose reduction (GDR) of an antipsychotic medication was clinically contraindicated. The resident had diagnoses including depression, anxiety, and schizoaffective disorder, and had a physician’s order for quetiapine 25 mg three times daily for agitation. A mental health progress note documented that a GDR of the antipsychotic was contraindicated due to the resident’s history of agitation and underlying schizoaffective disorder, and the Medication Administration Record showed the resident received quetiapine routinely over a specified period. However, the quarterly MDS assessment, while indicating that the resident received antipsychotic medication on a routine basis, did not include the physician-documented contraindication to GDR. During an interview, the MDS nurse stated she did not see the contraindication when coding the MDS, and the Administrator acknowledged that the MDS should have been coded to reflect the contraindication to gradual dose reduction of the antipsychotic medication.
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