Incorrect MDS Coding for Pressure Ulcers on Admission
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in relation to pressure ulcers. For one resident, documentation showed a pressure area was present on admission, and the 5-day MDS assessment indicated one Stage 2 pressure ulcer. However, the section indicating whether the Stage 2 ulcer was present on admission was incorrectly coded as zero. The resident's care plan also confirmed the presence of a pressure area on the coccyx upon admission, and the MDS nurse acknowledged the coding error during an interview. For another resident, both the hospital discharge summary and the facility's admission note documented a Stage 2 pressure injury on the right heel at the time of admission. Despite this, the 5-day MDS assessment did not code the resident as having a pressure ulcer or being at risk, and the section for unhealed pressure ulcers was marked as zero. The MDS Coordinator confirmed in an interview that this was an incorrect coding, as the resident did have a Stage 2 pressure ulcer present on admission.