Failure to Accurately Complete MDS Assessments for Resident with Multiple Skin Issues
Penalty
Summary
The facility failed to complete accurate and timely Minimum Data Set (MDS) assessments for a resident with multiple skin issues. Clinical record and facility policy reviews revealed that the MDS assessments did not accurately reflect the resident's skin condition, including the presence and progression of diabetic foot ulcers, pressure areas, and other skin breakdowns. The MDS forms often omitted documentation of existing wounds, failed to identify the resident's risk for pressure ulcers, and did not consistently record the use of pressure-reducing devices or turning/repositioning programs. Multiple assessment forms lacked comprehensive documentation of the resident's skin status, and there were gaps in the assessment of specific areas, such as the left pinky toe, prior to documentation of healing. The resident involved had significant cognitive impairment, was dependent on staff for activities of daily living, and had diagnoses including type II diabetes mellitus, Alzheimer's disease, non-Alzheimer's dementia, and malnutrition. Despite being at risk for pressure ulcers and having a history of diabetic ulcers and other skin breakdowns, the facility's assessments were incomplete and did not consistently capture the resident's actual condition. Interviews with staff confirmed a lack of clarity and continuity in wound descriptions, further contributing to the inaccuracy of the assessments.