MDS Alert
Chart The Good News About A Resident With A Wound
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Spell out how the resident is doing well.
Suppose a nurse doesn't document that a patient with a pressure ulcer is stable, reasoning that good news is no news.
Yet the nurse has actually assessed the resident and observed that he's "well hydrated, the dressing is intact without drainage and he says he's not in pain--and his intake is good," says Donna Senft, PT, JD, with the law firm of Ober/Kaler in Baltimore. But then three weeks later, lab tests show the "resident's albumin is low and his creatinine and BUN are abnormal," says Senft. In such a case, "surveyors might claim that the nurse didn't assess the resident and wound adequately all along," says Senft. And they will cite F314 or other tags--for example, "shortfalls in care planning."
Best advice: If the resident has a pressure ulcer, the documentation should address the issues in the F314 guidelines. Those include "risk factors, nutrition, positioning, hydration, pain."
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