Inaccurate MDS Assessments for Dental Status and Pressure Ulcers
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies in the documentation of dental status and pressure ulcer presence. For one resident, who was admitted with cachexia, dysphagia, and malignant neoplasm, the clinical record and dental consult indicated the presence of full upper and lower dentures, both of which were loose fitting. The resident was edentulous and only wore the upper dentures for eating, while the lower dentures were never worn due to poor fit. Despite these findings, the MDS assessments consistently failed to document the resident's edentulous status and the presence of loose dentures, instead indicating no dentures or dental concerns. Interviews with staff confirmed the resident's dental status and the inaccuracies in the MDS coding. For another resident with diagnoses including diabetes mellitus type II, acute kidney failure, and dependence on renal dialysis, the care plan and treatment records showed the presence of an unstageable right heel pressure injury and a stage 2 pressure injury on the left foot. Wound care treatments were documented for both sites during the relevant observation period. However, the most recent MDS assessment did not reflect the presence of any unhealed pressure ulcers, contrary to the clinical documentation and wound assessment report. The MDS Coordinator acknowledged that the assessment should have been coded to indicate the pressure ulcers present during the look-back period. These deficiencies were identified through record review, direct observation, and staff interviews, which revealed discrepancies between the residents' clinical conditions and the information recorded in the MDS assessments. The failure to accurately code for dental status and pressure ulcers resulted in incomplete and inaccurate resident assessments.