Inaccurate Discharge MDS Fails to Reflect Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure the accuracy of the discharge Minimum Data Set (MDS) for a resident who was admitted with quadriplegia, cervical spine fusion, and bacteremia. Upon admission, the resident was noted to have skin discoloration and an old pressure scar, but no open wounds. Shortly after admission, documentation indicated the development of an open area on the coccyx, and a wound physician later diagnosed a stage 4 pressure ulcer at that site following surgical debridement. Despite this diagnosis, the discharge MDS did not reflect the presence of the stage 4 pressure ulcer, instead only documenting two unstageable pressure injuries that were present upon admission. The MDS Coordinator confirmed during interviews and record reviews that the discharge MDS should have included the stage 4 pressure ulcer but did not, resulting in an inaccurate assessment of the resident's skin condition at discharge.