Inaccurate MDS Assessment and Documentation of Compression Dressings
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident with venous insufficiency and peripheral vascular disease. The annual MDS for this resident did not document the presence of continuous compression dressings, specifically unna boot dressings, which were observed on both legs during surveyor observations. The MDS indicated that no non-surgical dressings were applied, and the skin assessment did not note any alterations or the presence of dressings. Surveyors observed the resident wearing discolored and dirty dressings on both legs, extending from mid-foot to the knee, with the dressings in direct contact with the floor and not dated. These observations were made on consecutive days, and the condition of the dressings remained unchanged. Interviews with the MDS nurse and the Director of Nursing confirmed that the dressings should have been documented in the MDS and that nursing assessments are expected to accurately reflect the resident's status. Facility policy requires comprehensive assessments to be conducted and coordinated by a registered nurse with input from the interdisciplinary team.