Failure to Accurately Reflect Resident's Functional Limitation in MDS Assessment
Penalty
Summary
Nursing staff failed to accurately code Section GG of the MDS Comprehensive assessment for a resident with multiple diagnoses, including myopathy, rheumatoid arthritis, osteoarthritis, osteoporosis, osteopenia, contractures, chronic pain, and muscle atrophy. Despite documentation in the care plan and physician's progress notes indicating the resident had contractures and decreased range of motion in the upper extremities, the MDS assessment did not reflect any impairment in the resident's upper extremity function. Observations and interviews confirmed the resident had visible hand contractures and required staff assistance for transfers. The MDS Coordinator acknowledged that the assessment did not capture the resident's limited range of motion due to contractures. Both the DON and Administrator stated that accurate MDS records are essential for proper care planning and regulatory compliance. Facility policy requires comprehensive assessments to be conducted according to established criteria and timeframes.