Help please

If during the Quarterly look back period the skin assessment designated the site as a wound, without additional documentation to disprove it wasn't, then you coded it correctly as such. In other words there is no need to create a Significant correction of a prior assessment.

A skin tear due to shearing on a pressure point left unattended can lead to a pressure ulcer. Since it's now identified as a St III then code it in the MDS as a new pressure ulcer. You may also want to check whether 2 areas of decline for a Sig Change is met. The emergence of a new pressure ulcer at St II or higher is one. Another area of decline will validate changing the MDS type from Annual to SCSA.

Thank you so much for taking time and responding.

Talino should I also coded it as worsening since its was wound and it's now a pressure ulcer ?

Thank you so much for your help.

Talino should I also coded it as worsening since its was wound and it's now a pressure ulcer ?

Worsening” is actually defined in the RAI as a pressure ulcer that has progressed in stage, from 1-4. Since yours was initially a "wound" it doesn't meet the definition.

However, you will still code it in M0800 as a Stage 3 because it is "new" or it was not present on the prior assessment.

State is coming toour Facility soon. I am so scared this is my first state survey as an MDSC. Wehave one patient I am very scared we are going to get tag because we didn'topen a SCSA for a new pressure ulcer of sacrum stage 3 on time. During thatperiod when I found out, that I closed my QRTLY assessment without coding M0100A as yes (I though patient still w/out skin impairment) I just went back andmodified QRTLY assessment and coded it in Section M without changing QRTLY toSCSA. Now i am working on annual assessment and I am thinkingto the MDS type from Annual to SCSA, since not only St 3 pressure ulcer notheeled yet, another new pressure ulcer of Rt heel, St 2 noted during lookingback period of this annual assessment.

I just went back andmodified QRTLY assessment and coded it in Section M without changing QRTLY toSCSA. Now i am working on annual assessment and I am thinkingto the MDS type from Annual to SCSA, since not only St 3 pressure ulcer notheeled yet, another new pressure ulcer of Rt heel, St 2 noted during lookingback period of this annual assessment.

Please read the RAI p5-12 to 5-13 regarding "When any significant error is discovered in an OBRA comprehensive or Quarterly assessment..."

Significant correction of a prior assessment is a 2-prong process. If I understand you correctly, you created a modification of a previous quarterly just recently? That would be process #1. The 2nd process is to create either a SCPA or SCSA. By your statement, the SCSA is warranted. From the day you modified the Quarterly and noted it should be a significant change, you have up to 14 days to complete the SCSA. In that case, change your Annual MDS to SCSA now.

Thank you Talino