Inaccurate MDS Coding for Wounds and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to accurately code the MDS assessments for wounds and medications for two residents. One resident was admitted with a diagnosed Stage 4 pressure ulcer of the sacral/coccyx area, documented in the care plan as a chronic Stage 4 wound with interventions such as an alternating air mattress, regular skin assessments, turning and repositioning, and enhanced barrier precautions. Wound care provider notes, physician orders, and the Treatment Administration Record all documented a Stage 4 pressure ulcer with daily wound care and weekly wound care provider visits. However, the quarterly MDS dated 01/05/26 did not reflect any diagnosis of a pressure ulcer, did not code an unhealed pressure ulcer or a Stage 4 pressure ulcer, and did not indicate that pressure ulcer care was provided. The Wound Nurse confirmed the presence of the Stage 4 coccyx wound present on admission and ongoing daily treatment, and the MDS Coordinator acknowledged that the pressure ulcer was overlooked and the MDS was completed incorrectly. The second resident was admitted with type 2 diabetes mellitus with hyperglycemia and had a physician order for daily evening subcutaneous insulin glargine injections, which were documented as administered on the Medication Administration Record. A care plan was initiated for diabetes mellitus with interventions including administering medications as ordered, monitoring for hyperglycemia and hypoglycemia, providing a therapeutic diet, and obtaining labs as ordered. Despite this, the admission MDS dated 12/21/25 did not indicate that the resident received insulin injections or hypoglycemic medications. The MDS Coordinator confirmed that the resident received daily insulin and stated that the MDS assessment should have included both insulin injections and the use of hypoglycemic medication, acknowledging that these were overlooked and the MDS was coded incorrectly.
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