Inaccurate MDS Documentation of Pressure Ulcer Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Comprehensive MDS assessment accurately reflected the resident’s current pressure ulcer status. The resident had been admitted with multiple serious medical conditions, including chronic respiratory failure with hypoxia, tracheostomy with ventilator dependence, hemiplegia/hemiparesis, and vascular dementia, and lacked capacity to make decisions, with a daughter designated as responsible party. A wound care note dated May 19, 2025 documented a sacral fragile skin scar tissue reopening, measuring 3 cm in length, 1 cm in width, and 0.1 cm in depth, and included a physician’s order to cleanse with normal saline, apply Triad cream, and cover with a dry dressing for 30 days. Despite this documented wound and active treatment orders, the Quarterly MDS assessment for the same period indicated that the resident had no unhealed pressure ulcer injuries and was not receiving pressure ulcer care. During a concurrent interview and record review on February 18, 2026, the Nurse Manager confirmed that the wound care note showed a reopened pressure ulcer with specific treatment orders, and acknowledged that the MDS assessment did not reflect the resident’s actual pressure ulcer status. The Nurse Manager also stated that the facility follows the federal mandate for MDS assessments, and the cited RAI Manual language emphasized that MDS information must cover the specified observation period and be validated for accuracy by the IDT, which did not occur in this case.
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