Failure to Accurately Code MDS for Vascular Wound
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was accurately coded for a resident with a vascular wound. Record review showed that the resident was admitted with multiple diagnoses, including dementia, CVA with left-sided hemiparesis, obesity, chronic pain, diabetes mellitus type II, and neuropathy. Wound care notes initially described a wound on the left shin as a diabetic wound, but subsequent documentation reclassified it as a vascular wound. Despite this, the most recent MDS assessment did not code for venous or arterial ulcers under section M1030, even though the look-back period included the time when the wound was documented as vascular. Further review of the Resident Assessment Instrument (RAI) User's Manual confirmed that the presence of venous and arterial ulcers should be documented and used to inform the resident's care plan. During an interview, the Resident Care Manager stated that the facility had previously relied on a contracted wound care provider for wound classification and had discovered issues with incorrect classification of wounds. This led to the use of a different provider for more accurate wound identification. The failure to accurately code the MDS assessment for the resident's vascular wound constituted a deficiency in ensuring accurate assessment and documentation.