Inaccurate MDS Coding of Surgical Wound
Penalty
Summary
The facility failed to accurately assess a resident's surgical wound during the Minimum Data Set (MDS) process. According to the RAI 3.0 User's Manual, a pressure ulcer that has been surgically closed with a flap or graft should be coded as a surgical wound, even if the flap fails, until it is healed. Record review showed that the resident had a sacral pressure ulcer that underwent a failed flap surgery, as well as an unstageable pressure ulcer on the left ischium. Despite this, the significant change and discharge MDS assessments coded the sacral wound as a stage 4 pressure ulcer rather than as a surgical wound, contrary to the RAI manual's guidance. Interviews with the MDS nurse and the Director of Nursing confirmed that the sacral wound was not coded correctly on the MDS. The MDS nurse acknowledged following the RAI manual but admitted to inaccurately coding the wound as a pressure ulcer instead of a surgical wound. The Director of Nursing also confirmed the incorrect coding and stated an expectation for accurate MDS assessments. This failure to accurately assess and code the resident's wound was identified through both record review and staff interviews.