Inaccurate MDS Assessment for Pressure Ulcer
Penalty
Summary
Facility staff failed to complete an accurate Minimum Data Set (MDS) assessment for one resident who was admitted with multiple diagnoses, including cerebrovascular accident, hemiplegia, atrial fibrillation, aphasia, cognitive communication deficit, diabetes, dysphagia with gastrostomy, dementia, hypertension, and a pressure ulcer. The resident's clinical record documented the presence of a stage 2 sacral pressure ulcer upon admission, with corresponding physician orders and daily wound care treatments recorded in the treatment administration records. Despite this documentation, the admission MDS completed for the resident did not indicate the presence of any unhealed pressure ulcers or injuries in Section M0210, omitting the sacral pressure ulcer that was present and being treated. During an interview, the RN MDS coordinator acknowledged that the pressure ulcer should have been coded on the MDS as present upon admission and attributed the omission to an oversight. The deficiency was confirmed through staff interview and clinical record review, and was discussed with facility leadership during the survey.