Inaccurate MDS and Wound Documentation for Pressure Ulcers/Injuries
Penalty
Summary
The facility failed to ensure accurate assessment and documentation of a resident’s pressure ulcers/injuries (PU/PIs) from admission through discharge. On admission, the Nursing Database-Skin Integrity dated 12/04/2025 documented two coccyx wounds as skin tears, while the DON later stated the resident actually admitted with two Stage II PU/PIs on the coccyx, indicating the admission documentation was inaccurate. A daily skilled progress note on 12/08/2025 described a PU/PI with drainage and dead tissue but did not include the anatomical location, stage, or measurements. The 12/10/2025 admission MDS coded the resident as at risk for PU/PIs with no unhealed PU/PIs, and the 12/15/2025 PU/PI CAA did not document the rationale for care plan decisions, including complications, risk factors, or resident-centered care needs. Subsequent MDS assessments and modifications contained inconsistent and incomplete coding of the resident’s PU/PIs. A Significant Change MDS dated 01/22/2026 showed one Stage IV PU/PI present on admission, while a 12/10/2025 admission MDS modification dated 01/27/2026 coded one unstageable PU/PI on admission. A later admission MDS modification dated 02/11/2026, submitted after discharge, indicated one unhealed PU/PI but did not include the number or stage of the wound. The MDS coordinator reported there was no supporting documentation for a PU/PI on admission and that the earlier coding of an unstageable PU/PI present on admission was incorrect; the records were then modified to show a Stage IV PU/PI that was not present on admission and had developed at the facility. Additionally, a Wound Care Consultant form dated 02/05/2026 documented a new DTI on the right heel, but the discharge MDS dated 02/10/2026 did not code this DTI, which the MDS coordinator attributed to the wound tracker form not being available in the clinical record at the time of MDS completion.
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