Inaccurate MDS Assessment for Pressure Ulcer
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for a resident, identified as Resident 59. A review of the resident's clinical record revealed discrepancies in the documentation of a Stage 3 pressure ulcer. An MDS assessment dated July 11, 2024, indicated that the resident had a Stage 3 pressure ulcer present on admission, with no other skin issues noted. However, a subsequent MDS assessment indicated that the same pressure ulcer was not present on admission. An interview with the Administrator confirmed that the MDS dated October 11, 2024, was coded in error regarding the resident's pressure ulcer status. This discrepancy highlights a failure in accurately assessing and documenting the resident's condition as required by the facility's protocols.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Resident 59's MDS was corrected at the time of survey to reflect the Stage 3 pressure ulcer was not facility acquired. 2. All MDS for residents with facility acquired pressure ulcers in the last 2 months were reviewed for accuracy. 3. The RNACs were educated on accurate MDS coding of facility acquired pressure ulcers. 4. Audits will be completed for MDS coding of facility acquired pressure ulcers weekly x4 then monthly x2 with results reported to QAPI. 5. Compliance date: January 28, 2025