Inaccurate MDS Assessments for Resident Behaviors, Discharge Status, and Pressure Ulcer Staging
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for three residents, resulting in deficiencies related to the assessment and documentation of resident conditions and behaviors. For one resident with severe cognitive impairment and a history of pacing and wandering, the MDS assessment did not reflect the documented and observed behaviors of intrusive wandering and pacing, despite consistent documentation of these behaviors in the medical record and observations by staff. The Director of Nursing confirmed that these behaviors should have been coded on the MDS if they were occurring during the look-back period. Another resident was discharged home, but the discharge MDS was incorrectly coded as a planned discharge to an acute hospital. The Director of Nursing confirmed that the resident was discharged home and that the MDS should have been coded accordingly. The MDS Coordinator was not available for interview regarding this discrepancy. A third resident with a long-standing stage 4 pressure ulcer was incorrectly coded on the MDS as having a stage 2 pressure ulcer. Medical records and wound consultant notes indicated the presence of a stage 4 pressure ulcer, and staff interviews confirmed the wound had improved but was still present. The Director of Nursing stated the wound was now a stage 2 ulcer, which was why it was coded as such, despite clinical standards requiring that a healing stage 4 ulcer continue to be documented as stage 4 until fully healed.