Failure to Accurately Document Pressure Ulcer on MDS Assessment
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident, resulting in the omission of a pressure ulcer that was present upon the resident's re-admission. The resident, who had diagnoses including diabetes, schizoaffective disorder, hypertension, and lack of coordination, was re-admitted to the facility with an existing wound to the buttocks. Nursing progress notes documented the presence of this wound and indicated that it was being treated according to wound care orders. The Treatment Nurse confirmed that the pressure ulcer was present at re-admission and reported it to the MDS Nurse during the morning meeting. Despite this, the MDS assessment completed for the resident did not document the pressure ulcer. The MDS Nurse, who was responsible for completing the assessment, stated that she typically gathered wound information from weekly wound reports, skin assessments, and interdisciplinary team meetings, but acknowledged that she missed documenting the wound in this instance. The facility's policy requires accuracy and timeliness in MDS completion, but this was not followed, resulting in an inaccurate assessment for the resident.