Penalty

90 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident with a history of multiple medical conditions, including dementia, type II diabetes, protein calorie malnutrition, age-related physical debility, and hemiplegia/hemiparesis following cerebrovascular disease. The resident, who was non-interviewable and had severe cognitive impairment, was identified for review due to a facility-acquired pressure ulcer. Review of the resident's MDS skin assessments over several quarters showed inconsistent documentation regarding the presence of pressure ulcers, with the most recent quarterly MDS indicating a stage two pressure ulcer. However, examination of the electronic medical record (EMR), including assessments, progress notes, and miscellaneous documentation, did not reveal any supporting evidence of a pressure ulcer during the relevant look-back period. The MDS Coordinator reported coding the pressure ulcer based on an earlier progress note and the absence of documentation indicating healing, despite a subsequent note stating the wounds were healed. Review of the RAI manual confirmed that coding should be based on the presence of a pressure ulcer within the 7-day look-back period, which was not supported by the available documentation. The MDS Coordinator acknowledged the MDS was coded incorrectly for a pressure ulcer.