Inaccurate MDS Coding for Resident with Multiple Arterial Ulcers
Penalty
Summary
The facility failed to ensure the accuracy of a resident's Minimum Data Set (MDS) assessment regarding the presence of venous and arterial ulcers. Specifically, the MDS for a resident admitted with diagnoses including sepsis, metabolic encephalopathy, and acute respiratory failure with hypoxia, was coded to indicate zero venous and arterial ulcers. However, a review of the resident's Wound Weekly Monitoring Assessment Non-Pressure, dated the day after admission, documented the presence of 12 arterial ulcers. During interviews and record reviews, the MDS Coordinator acknowledged that the MDS was coded in error and should have reflected the number of arterial ulcers as documented in the wound assessment. The Director of Nursing also confirmed that the MDS should have been coded accurately to ensure the resident received timely care and treatment. The facility's policy required that assessments represent an accurate picture of the resident's status during the observation period, which was not followed in this instance.