Inaccurate Coding of MDS Assessment for Pressure Ulcer on Admission
Penalty
No penalty information released
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Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident. Upon admission, the resident had a pressure wound on her right ankle, as documented in a nursing progress note. However, the admission MDS assessment incorrectly indicated that the unhealed, unstageable pressure ulcer was not present on admission. This inaccuracy was confirmed by both the MDS Nurse, who acknowledged the error in coding, and the facility Administrator, who stated that the assessment should have accurately reflected the resident's condition at the time of admission.