Inaccurate MDS Assessment of Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's health and functional status, specifically regarding the presence and stage of a pressure ulcer. A resident with a history of dysphagia, hemiplegia, hemiparesis, and shortness of breath was observed with a low air loss mattress and had an ongoing pressure ulcer on the right buttock, initially diagnosed as an unstageable pressure injury and later changed to a Kennedy ulcer with stage 3 appearance. Despite ongoing treatment for the open ulcer, the MDS quarterly assessment did not code the presence of any ulcer, which the MDS nurse acknowledged as an error in coding and an inaccurate assessment. Interviews with facility staff revealed that the Director of Nursing did not verify the accuracy of MDS assessments and relied on the staff responsible for completing them to ensure correctness. The MDS nurse admitted to the coding error, and the administrator confirmed the expectation for accurate, complete, and timely assessments. Facility policy required qualified staff to conduct accurate assessments and document medical and functional problems, but this was not followed in this instance, resulting in the resident's pressure ulcer not being properly documented in the MDS.