Inaccurate MDS Assessment Due to Incomplete Wound Documentation
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) admission assessment accurately reflected the status of a resident who had a pressure wound. Specifically, the MDS for this resident did not indicate the presence of a pressure ulcer, despite the resident's medical record and diagnoses confirming its existence. The resident, a male with multiple diagnoses including spinal stenosis, atherosclerotic heart disease, hypertension, spondylosis, dementia, diabetes mellitus, hemiplegia, and a sacral pressure ulcer, was admitted to the facility and had a severely impaired cognition as indicated by a BIMS score of 3. Interviews with facility staff revealed that the MDS nurse relied on the wound care report to complete the MDS, but the former wound care nurse had not kept the wound care report up to date and had failed to include this resident. As a result, the MDS nurse did not document the pressure wound on the MDS. Both the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the wound care report was incomplete and that the information should have been included in the MDS assessment, as required by facility policy.