Inaccurate Documentation of Extremity Impairment in MDS Assessment
Penalty
Summary
The facility failed to accurately document the upper and lower extremity impairment status for one resident with significant neurological diagnoses, including quadriplegia and paraplegia. Review of the Minimum Data Set (MDS) assessment indicated that the resident was documented as having no impairment in both upper and lower extremities, despite medical records and care plans noting a history of quadriplegia and paraplegia, which are conditions characterized by loss of movement and sensation. The MDS also recorded the resident as dependent or requiring substantial assistance for toileting hygiene and bathing, which further contradicts the documentation of no impairment in extremities. Interviews with the resident and the resident's spouse confirmed that the resident had no sensation from the chest down, with only minimal functional ability in one hand, and limited grasping abilities in both hands. The resident reported difficulty moving fingers and performing tasks, and the spouse corroborated these limitations. When questioned, the Regional MDS consultant stated that any capacity to move a joint was considered as no impairment, but did not provide a clear response regarding the documentation of impairment for residents with paraplegia or hemiplegia. This discrepancy between the resident's actual condition and the MDS documentation led to the identified deficiency.