Inaccurate MDS Coding for Pressure Ulcer Staging
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) was accurately coded to reflect the correct staging of pressure ulcers for a resident. The resident, who was admitted with diagnoses including dehydration, Parkinson's disease, anxiety, and weakness, was assessed as being at moderate risk for pressure sores according to the Braden Scale. Multiple wound assessments documented varying descriptions and stages of pressure ulcers, including an unstageable ulcer on the left buttock, a wound on the left iliac crest with tunneling and purulent drainage, and a stage I ulcer on the left buttock. There were inconsistencies in the wound documentation, such as incomplete wound characteristics and discrepancies in wound staging and descriptions across different assessments. During an interview, an RN responsible for coding the MDS stated that she relied on the nursing data collection, which indicated an unstageable pressure ulcer on admission, leading her to code it as such. The RN also acknowledged issues with the facility's wound charting. These actions and documentation inconsistencies resulted in the MDS not accurately reflecting the resident's pressure ulcer status, constituting a deficiency in the facility's assessment process.