Inaccurate MDS Coding for Resident With Documented Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate admission MDS assessment for a resident with documented pressure ulcers. The resident, a 65-year-old female admitted with a diagnosis of sacral pressure ulcer, had an admission MDS dated 02/03/2026 that coded Section M (Skin conditions) as indicating no unhealed pressure ulcers/injuries. However, the resident’s face sheet listed a diagnosis of pressure ulcer of the sacral region, and a wound care assessment dated 02/02/2026 documented stage 2 pressure ulcers on the left and right buttock. A physician order dated 02/04/2026 directed daily wound care to the left and right buttock stage 2 pressure ulcers using triad with collagen particles. Further record review showed the comprehensive care plan dated 01/30/2026 addressed deep tissue injuries to both heels with interventions such as a pressure-reducing mattress, skin care, treatment, and turning/repositioning, but did not include a care plan for the resident’s buttock pressure ulcers. During interviews, a hospital nurse and the facility’s wound care LVN confirmed the presence of stage 2 pressure ulcers on both buttocks at admission and that wound care was being provided. The DON acknowledged that the admission MDS was inaccurate regarding pressure ulcers and stated that Section M should have been coded to reflect one or more unhealed pressure ulcers/injuries. The facility’s policy on documentation required each resident’s medical record to contain a complete and accurate representation of the resident’s status and progress.
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