Inaccurate MDS Coding for Weight and Wound Count
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded accurately for one resident. Specifically, the quarterly assessment recorded the resident's weight as 155 pounds, which was the admission weight, instead of the correct weight of 141 pounds documented seven days prior to the assessment. Additionally, the discharge return anticipated assessment inaccurately documented the number of unstageable wounds as five, while the wound care provider's note indicated there were only four unstageable wounds present at that time. These inaccuracies were confirmed by the MDS Coordinator, who acknowledged the errors in both the weight and wound count coding. The resident involved had a history of peripheral vascular disease, stroke, and diabetes, and was cognitively intact at the time of the assessments. The facility's policy and the RAI manual require accurate and validated assessments, but these requirements were not met in this instance.