Inaccurate MDS Assessment for Pressure Ulcers
Penalty
Summary
The facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for a resident in the area of pressure ulcers. Review of the resident's electronic health record showed that a skilled evaluation identified pressure ulcers on the sacrum, left heel, and left elbow. However, the subsequent quarterly MDS assessment did not accurately reflect the presence of these unhealed pressure ulcers, as item M0210 was incorrectly marked 'No,' indicating the resident did not have any unhealed pressure ulcers or injuries. This error resulted in the omission of required documentation regarding the number and stage of the resident's pressure ulcers on the MDS assessment. The Coordinator for Clinical Reimbursement later confirmed that the MDS assessment was incorrect.