Inaccurate MDS Assessment of Resident Wounds
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s MDS assessment accurately reflected his clinical status, specifically his skin conditions and wounds. The admission MDS for a male resident with diagnoses including heart failure, wound infection, paraplegia, malnutrition, chronic bone infection, and a Stage III pressure ulcer documented only the Stage III pressure ulcer and did not indicate any other wounds. However, the resident’s care plan identified an actual impairment to skin integrity related to a non-pressure chronic ulcer on the right leg, with interventions to monitor and document the wound and report abnormalities to the physician. Additionally, the facility’s wound care report showed that the resident had an atypical lesion on the right leg, an atypical lesion on the left leg, and a Stage III pressure ulcer on the coccyx, all present on admission. Surveyors were unable to interview the MDS Coordinator, who did not return calls. The DON stated she did not sign the MDS assessment for this resident and did not know who was responsible for ensuring MDS assessments were correct, though she acknowledged their importance for ensuring appropriate care interventions. The Corporate Nurse reported that she signed the MDS assessment to show it was completed, while the MDS Coordinator actually filled it out. Facility policy on resident assessments indicated that a comprehensive assessment includes completion of the MDS and that the interdisciplinary team uses the MDS form mandated by federal and state regulations to conduct the resident assessment. Despite this policy, the resident’s MDS did not accurately capture all existing wounds documented elsewhere in the record.
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