Inaccurate MDS Skin Assessment for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to complete an accurate MDS assessment regarding skin conditions for one resident. The resident was admitted with diagnoses including a left patella fracture, A-fib, CHF, hypothyroidism, and Alzheimer’s disease. On admission, a nurse documented a dark spot on the coccyx, an open area on the spine, and redness to the left knee. The resident’s care plan, initiated the day after admission, identified her as being at risk for skin breakdown and included general preventive skin care interventions such as patting the skin dry, observing for signs of breakdown, using barrier creams, and checking the skin weekly by a licensed nurse. Despite these documented skin findings and risk factors, the admission MDS indicated that the resident was severely cognitively impaired and required extensive assistance with ADLs but did not accurately reflect her existing skin issues. The MDS stated that the resident did not have a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing or device, and under other ulcers, wounds, and skin problems, it indicated none were present. The MDS also did not indicate the need for a pressure-relieving device in the chair, participation in a reposition/turning program, or inclusion in a nutrition and hydration program for skin, resulting in an inaccurate assessment of the resident’s skin condition and related care needs.
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