Inaccurate Coding of Pressure Injuries on MDS Assessments
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two of six sampled residents. For one resident, the number of Stage 1 pressure injuries was incorrectly coded as two instead of one in section M of the MDS. This error was identified when the MDS Coordinator, upon reviewing the Treatment Administration Record and Nurse's Progress Notes, confirmed that only one Stage 1 pressure injury was present, not two as documented. The MDS assessment had been completed by a different coordinator, and the error was verified through record review and staff interviews. For another resident, the number of Stage 3 pressure injuries was inaccurately coded as four instead of three on the MDS. The Wound Care Nurse confirmed the presence of three pressure injuries, and the MDS Coordinator, after reviewing relevant records, verified that only three Stage 3 pressure injuries existed. Both residents had significant medical histories, including conditions such as subdural hematoma, vascular dementia, Parkinson's disease, acute blood loss, and chronic ulcer. The inaccurate coding of pressure injuries on the MDS had the potential to negatively affect the care and services provided to these residents.