Failure to Complete Accurate and Timely MDS Assessments for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to complete accurate and timely Minimum Data Set (MDS) assessments for two residents with pressure ulcers. For one resident, the MDS inaccurately indicated the presence of a tracheostomy and the need for tracheostomy care, despite direct observation, resident interview, and staff confirmation that the resident did not have a tracheostomy or require related care. The error was acknowledged by the MDS nurse, who confirmed the assessment was incorrect. For another resident, staff interviews and record review revealed that a new pressure ulcer developed on the resident's left heel, but a required change in condition MDS assessment was not completed within the mandated timeframe. The MDS nurse confirmed that the development of a new pressure ulcer should have triggered a change in condition assessment, but this was not done. The failure to complete accurate and timely assessments was confirmed through interviews with nursing and MDS staff, as well as review of the residents' medical records.