Inaccurate MDS Coding of Resident Skin Conditions and Wounds
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the Minimum Data Set (MDS) assessments accurately reflected a resident’s skin condition and wounds. During an abbreviated survey, it was identified that one sampled resident had cellulitis and multiple wounds documented in hospital discharge records and facility admission notes, but these conditions were not captured on the resident’s MDS assessments. An MDS dated in July 2025 documented no skin problems or pressure ulcers, despite hospital records and a Patient Review Instrument from mid-July 2025 indicating bacteremia with cellulitis, a full-thickness wound on the lower right extremity, and the need for wound care for stasis ulcers. Further record review showed that when the resident was discharged again from the hospital in late December 2025, the hospital discharge summary listed multiple significant wounds, including a Stage III sacral ulcer, deep tissue injuries to the left hip and both heels, an unstageable right hip wound, dry gangrene of toes, black necrosis of the right great toe, and a partial-thickness wound at the left bunion. A nursing admission/readmission note from early January 2026 documented pressure wounds to the sacrum, wounds to both hips, and gangrene to all toes and both heels. However, a wound/skin assessment by the facility’s wound care nurse on January 5, 2026, described only a right hip superficial abrasion, moisture-associated dermatitis to the sacrum, and unremarkable bilateral lower extremities, heels, and feet, which did not correlate with the hospital discharge assessment. An MDS dated January 9, 2025, recorded the resident as having moderately impaired cognition and documented only moisture-associated skin damage in the skin condition section, with no evidence that the unstageable right hip ulcer, gangrenous toes, or left bunion wound were assessed or coded. Interviews with the MDS coordinator revealed that they reviewed the hospital discharge records and were aware of multiple wounds but relied on the wound nurse’s assessment without physically assessing the resident’s skin or reconciling discrepancies between hospital and facility documentation. The MDS director stated that MDS completion is based on assessments documented in the medical record and acknowledged that ulcers in the hospital records may have been overlooked. These actions and inactions resulted in MDS assessments that did not accurately reflect the resident’s actual skin status, contrary to the facility’s MDS Completion Policy and regulatory requirements.
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