Inaccurate MDS Coding for Pressure Ulcer Staging
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for one resident, resulting in the potential for inaccurate federal reimbursement and resident care planning. Specifically, a resident with a history of a stage three pressure ulcer on her right foot between her toes was incorrectly coded as having only a stage two pressure ulcer on the quarterly MDS assessment. Documentation and provider notes indicated that the wound had previously been assessed as a stage three ulcer and had recurred in the same location, but the MDS coordinator was unaware of the prior stage three diagnosis due to the absence of this information in the diagnosis list. As a result, the wound was not coded at its worst stage as required by the CMS Long-Term Care Facility Resident Assessment Instrument User's Manual. Interviews with nursing staff and the MDS coordinator confirmed that the wound was open and unhealed at the time of the assessment, and that the coding error occurred because the prior stage three ulcer was not documented in the diagnosis list. The facility's policy required all interdisciplinary team members to review the current RAI manual and for the MDS coordinator to conduct audits to identify and correct errors, but this process was not followed, leading to the inaccurate MDS coding for the resident.