Inaccurate MDS Assessment for Resident With Unstageable Pressure Injury
Penalty
Summary
The facility failed to complete an accurate MDS assessment for one resident by not documenting an existing unstageable pressure injury. The resident was admitted with multiple diagnoses, including an intracapsular right femur fracture, type 2 diabetes mellitus, systemic lupus erythematosus, age-related osteoporosis, unspecified dementia without behavioral disturbance, and generalized muscle weakness. Nursing progress notes documented ongoing skin checks, including right hip and right lower extremity assessments, and on one date a new in-house acquired unstageable pressure wound to the coccyx was identified. Subsequent nursing documentation noted family presence for wound care and teaching related to this unstageable coccyx pressure injury. Weekly skin assessments for the resident showed that on one date there was no pressure injury, but later entries documented an unstageable pressure injury to the sacrum due to slough and then an unstageable in-house acquired pressure injury to the coccyx area. Despite these documented findings in the clinical record, the MDS assessment for the resident, dated within the same time frame, indicated in section M0210 that there were no unhealed pressure ulcers or injuries. During an interview, the MDS Coordinator confirmed that this MDS assessment did not accurately reflect the resident’s unstageable coccyx pressure injury.
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