Inaccurate MDS Assessments for Surgical Wound and Pressure Injury
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for a resident who was admitted with a surgical incision and later developed a stage 3 pressure injury. Upon admission, the resident had a surgical incision on the lower back, as documented by physician orders and care instructions, but the admission MDS assessment did not reflect the presence of a surgical wound, the need for surgical wound care, or the use of pressure-reducing devices. The assessment also did not indicate that the resident was on a turning or repositioning program, despite being at risk for pressure injuries and requiring moderate assistance with mobility. Subsequently, a wound clinic note documented a stage 3 sacral pressure injury, but the discharge MDS assessment failed to record the presence of this unhealed pressure injury. Interviews with the DON and MDS RN confirmed that both the surgical incision and the pressure injury should have been documented in the respective MDS assessments. The inaccuracy in the MDS assessments was identified through staff interviews and record review, demonstrating a failure to follow the facility's policy for conducting accurate resident assessments.