Failure to Accurately Document Pressure Ulcer on Assessment and MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the status of a pressure ulcer for one resident. Upon readmission, the resident returned with a sacral pressure ulcer, which was noted in the initial head-to-toe skin check and provider communication log. However, subsequent weekly skin assessments failed to document the presence of the wound, and the Minimum Data Set (MDS) assessment did not indicate the existence of a pressure ulcer, despite physician orders for wound care being in place. The MDS Coordinator relied on nursing documentation, which incorrectly showed the resident's skin as intact during the lookback period, leading to inaccurate reporting on the MDS. Interviews revealed that the facility did not have a dedicated wound care nurse, and wound care responsibilities were shared among nursing staff, with oversight from a wound care provider and nurse practitioner during weekly rounds. The Director of Nursing stated that unit managers are responsible for admission assessments, while floor nurses are expected to document ongoing skin issues. The deficiency resulted from incomplete and inaccurate documentation of the resident's pressure ulcer status in both the skin assessments and the MDS, despite clear evidence of the wound in other records.