Inaccurate Resident Assessment Due to Incomplete Review of Documentation
Penalty
Summary
The facility failed to ensure that a resident received an accurate assessment reflective of their status, as required by regulatory guidelines. Specifically, the Minimum Data Set (MDS) assessment completed for the resident did not accurately document the presence and staging of pressure injuries within the required look-back period. The MDS assessment indicated the resident had one unstageable pressure ulcer and one unstageable deep tissue injury present on admission, but nursing admission notes and assessments documented only redness and intact skin on the sacrum and heels, with no open wounds at that time. Subsequent progress notes and care plans indicated the development and evolution of skin breakdown after admission, with interventions and medical orders initiated in response to these changes. The MDS Coordinator, during interview, confirmed that the assessment was completed using documentation outside the required look-back period and did not review the admission note, admission assessment, or hospital paperwork. This resulted in inaccurate coding of the resident's pressure injuries on the MDS. The facility's policy requires gathering information from multiple sources and using various methods, including observation, interview, and record review, to ensure accurate resident assessments, but this process was not followed in this instance.