Inaccurate MDS Coding Due to Incomplete Pressure Ulcer Assessment
Penalty
Summary
The facility failed to accurately assess and code the Minimum Data Set (MDS) for a resident regarding the presence and staging of a pressure ulcer. Upon admission, the initial skin assessment conducted by a registered nurse indicated no pressure ulcers and documented only a rash on the sacrum. However, subsequent documentation by another licensed nurse the following day identified a new wound on the sacrum, but it was not staged at that time. The wound nurse stated that staging was typically done in conjunction with the wound nurse practitioner, who did not assess the wound until several weeks later. During this period, the wound was variously documented as a rash, a stage II pressure ulcer, and later as an unstageable ulcer, with changes in the care plan and physician orders reflecting these evolving assessments. The MDS nurse coded the resident's MDS as having a stage II pressure ulcer on admission, relying on later nurse practitioner notes rather than the initial admission assessment. The MDS nurse acknowledged not reviewing the initial assessment and recognized that the MDS should have been modified to accurately reflect the resident's status at admission. Interviews with nursing staff revealed inconsistencies in the assessment and documentation of the wound, with differing opinions on whether the wound was present and its stage at the time of admission. The Director of Nursing confirmed that initial admission skin assessments are expected to be completed accurately by an RN and that MDS coding should follow the Resident Assessment Instrument (RAI) Manual guidelines. The deficiency resulted from a lack of accurate and timely assessment, staging, and documentation of the resident's pressure ulcer status upon admission, leading to the submission of inaccurate information to the federal database. The facility's failure to ensure that the MDS accurately reflected the resident's condition at admission was confirmed through record review, staff interviews, and observation, as required by federal regulations.