Inaccurate MDS Assessment of Pressure Ulcers on Admission
Penalty
No penalty information released
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Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status regarding pressure ulcers and wounds. Specifically, a review of one resident's medical record showed that a skin check documented four wounds, with two of them (on the left hip and right heel) noted as present on admission. However, the corresponding MDS assessment did not indicate that these two wounds were present on admission, instead marking all four wounds as not present on admission. This discrepancy was identified during a surveyor's review of the records, and the error was acknowledged by the Regional MDS Coordinator, who confirmed that the MDS should have reflected the wounds as present upon admission.