Inaccurate MDS Coding for Pressure Ulcer and Discharge Status
Penalty
Summary
Facility staff failed to accurately code the Minimum Data Set (MDS) for two of three residents reviewed. For one resident, interviews with the resident and the Wound Care Coordinator confirmed that the resident had never been diagnosed with or treated for a stage 3 pressure ulcer while at the facility. Despite this, the resident's MDS documented the presence of one unhealed stage 3 pressure ulcer. Review of the resident's current and previous physician order sheets showed no wound treatment orders, further supporting that no pressure ulcer care was provided. For another resident, the MDS indicated a planned discharge to the hospital. However, progress notes and interviews with facility staff confirmed that the resident left the facility against medical advice (AMA) and was discharged to the community, not the hospital. The MDS nurse acknowledged the error, stating that the discharge destination was incorrectly coded due to a misunderstanding of the resident's actual discharge status. Documentation, including a signed Release of Responsibility form, supported that the resident left AMA.