F0641

D

Inaccurate MDS Coding of Sacral Pressure Injury Due to Late Wound Documentation

White Plains, New York Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that the Minimum Data Set (MDS) accurately reflected a resident’s pressure injury status. During an abbreviated survey, record review showed that the admission MDS, with an Assessment Reference Date (ARD) of 12/15/2025, coded the resident’s sacral wound as a stage 2 pressure ulcer in Section M, based on an admission nurse’s assessment from 12/08/2025. However, wound documentation showed that the wound care provider assessed the same sacral wound as unstageable due to necrosis on 12/09/2025, and a wound evaluation management summary dated 12/15/2025 also identified the sacral wound as unstageable. Additionally, the resident’s care plan for alteration in skin integrity documented an actual pressure injury identified as a sacral stage 4 with necrotic tissue, initiated on 12/09/2025.

The resident had diagnoses including COPD, vasculitis limited to the skin, and cellulitis of an unspecified limb. During interview, the MDS Coordinator stated they did not complete the assessment for this resident and primarily performed administrative tasks. The MDS Coordinator acknowledged that the 12/08/2025 admission nurse assessment documenting a stage 2 sacral wound was significantly different from the 12/09/2025 wound care provider assessment documenting an unstageable sacral wound. The MDS Coordinator further explained that the 12/09/2025 and 12/15/2025 wound care provider assessments were not uploaded into the system until 12/21/2025 and 12/22/2025, after the ARD 7‑day look‑back period, so the person completing the MDS only had access to the earlier stage 2 assessment. As a result, the MDS did not accurately capture the resident’s true wound status during the assessment period, contrary to facility policy and RAI manual guidelines.