Inaccurate MDS Coding of Facility-Acquired Sacral DTI
Penalty
Summary
Facility staff failed to ensure an accurate assessment for one resident by incorrectly coding a facility-acquired pressure injury on the Quarterly MDS. The resident was admitted with multiple diagnoses including Type 2 diabetes mellitus, Alzheimer's disease, dementia, muscle weakness, and major depressive disorder. On 10/29/25, nursing staff identified an open area on the resident's sacrum during routine ADL/incontinent care, and the NP, wound team, and dietitian were notified. On 10/30/25, a comprehensive skin and wound assessment documented a sacral pressure ulcer/injury with full-thickness tissue loss and a central area of marooning, and the wound team determined it would be followed as a deep tissue injury (DTI). On 11/11/25, a wound/pressure ulcer note documented a sacral DTI pressure ulcer/injury that was specifically identified as in-house acquired. Despite this documentation, the Quarterly MDS assessment coded the resident as having one unstageable pressure injury that was present upon admission, rather than facility acquired. During an interview, the MDS coordinator reviewed the MDS, acknowledged the discrepancy, and stated that the sacral wound had been miscoded as present on admission instead of correctly coded as not present on admission.
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