Inaccurate MDS Assessment of Resident Functional Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's current status. Clinical record review showed that the resident had diagnoses including non-traumatic subarachnoid hemorrhage, torticollis, and left hemiplegia, with documented impairments in strength and range of motion in the left upper extremity according to an occupational therapy evaluation. However, the MDS assessment did not identify the resident as having an upper extremity impairment in functional limitation in range of motion under section GG, Functional Status. This discrepancy was confirmed during an interview with the Administrator, who acknowledged that the MDS was not coded to accurately reflect the resident's condition.