F0641

D

Inaccurate MDS Coding of Existing Thigh Wound

Kerrville, Texas Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected the presence of an existing wound. The resident, a female with diagnoses including cerebral infarction, rash and other nonspecific skin eruption, and MRSA infection, was admitted with a right thigh wound. Her Quarterly MDS assessment, dated 12/23/2025 and signed complete on 01/12/2026, documented that she was cognitively intact with a BIMS score of 15, used a wheelchair, was dependent for bed mobility and transfers, and was at risk for pressure ulcers. However, Section M – Skin Conditions, completed by an LPN on 01/01/2026, indicated that she had no skin ulcers, wounds, or skin problems.

Contrary to the MDS coding, multiple clinical records showed the resident had an ongoing right medial/distal thigh wound. The care plan included a focus on wound management with an intervention to provide wound care per treatment order initiated on 11/04/2025. A nurse practitioner progress note dated 12/04/2025 referenced a right lower extremity thigh wound with MRSA. A skin issues progress note documented an abscess on the right medial thigh, and wound care orders on the Treatment Administration Record throughout January directed cleansing of a right distal thigh wound for a spider bite and later for lymphedema, with ongoing treatments and no discontinue date for some orders. A specialized skin and wound note dated 01/02/2026 described a pre-existing right medial thigh ulcer characterized as a lymphatic ulcer, and a wound assessment report dated 01/28/2026 identified the right medial thigh wound as a lymphatic ulcer acquired on 12/03/2025.

Surveyor observations and staff interviews further confirmed the presence of the wound and the inaccuracy of the MDS. On 02/06/2026, an LPN was observed performing wound care on a small wound on the resident’s right inner thigh, and the resident reported that staff performed wound care twice daily and that treatments had not been missed. The LPN wound nurse stated the resident had been admitted with the thigh wound, initially thought to be lymphatic. The LPN who completed Section M of the MDS did not recall the resident but stated she believed the wound should have been coded as an open ulcer and that she would normally refer to the RAI manual if a wound did not fit standard options. The DON reported being unfamiliar with MDS assessments or how assessment accuracy could impact care, while the administrator acknowledged that inaccurate MDS wound documentation could affect care planning because MDS entries trigger care plan development. Facility policies required comprehensive assessments per the RAI Manual and complete, accurate documentation, but the resident’s wound was not coded on the Quarterly MDS despite extensive documentation of its presence and treatment.