Inaccurate Assessment of Pressure Ulcer on Admission
Penalty
Summary
The facility failed to accurately assess a resident admitted with an unstageable pressure ulcer to the buttocks and pain. Upon review, the admission Minimum Data Set (MDS) indicated the resident was at risk for developing pressure ulcers and had one or more unhealed pressure ulcer injuries, but did not document the number of unstageable pressure ulcers due to non-removable dressings or devices. The section of the MDS addressing unstageable pressure ulcers present on admission or re-entry was left incomplete. Additionally, the skin and ulcer treatment section noted the use of a pressure reducing device and surgical wound care, but there was no documentation reflecting that the resident was receiving care for a pressure ulcer. The Director of Nursing Services acknowledged the inaccuracy of the MDS assessment.