Q:
I have a resident that was originally admitted to our facility with a stage 2 pressure ulcer who went out to the hospital for three days and returned with a stage 2 pressure ulcer in the same location. How would this be coded on the MDS?
A:
Completing a head-to-toe physical examination of the skin upon return from the hospital is an important step in assessing the resident’s condition. Timely documentation of the skin assessment ensures accurate monitoring of changes and promotes continuity and quality patient care.
For MDS coding, the key principles are (1) whether the pressure ulcer is considered present on admission/entry or reentry or a new facility-acquired ulcer and (2) whether it has changed in stage.
In this scenario:
-
- The resident already had a Stage 2 pressure ulcer when first admitted.
- They were discharged to the hospital.
- They returned with a stage 2 in the same location.
Per RAI guidelines:
This would be coded as present on admission (reentry). Since the stage is the same as when the resident left, it is not considered a new ulcer and is not considered worsened.
Assessing the resident’s skin and documenting the findings as close as possible to the resident’s return from the hospital helps ensure timely identification of any change and provides an accurate baseline for ongoing monitoring and treatment.
Next Steps:
- Register for Proactive’s virtual training Pressure Ulcer Management & Prevention Strategies on May 12, 2026 for key insights into improving quality outcomes, strengthening survey readiness and reducing clinical risk in this area.
- Make plans to attend Ship Shape QMs on May 13 ,2026
- Partner with Proactive for MDS coaching, support and real time responses to your questions with an as-needed consulting engagement
Written By:
Susan Pokorny, RN, GERO-BC, RAC-CT, RAC-CTA
MDS Consultant
Proactive LTC Consulting
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