Inaccurate MDS Coding for Functional Limitation in Range of Motion
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were accurately coded for a resident admitted for rehabilitation following a right revision total knee replacement and infection, with a wound vac in place. During review of the resident's admission MDS assessment, it was found that Section GG0115, which addresses functional limitation in range of motion, was incorrectly coded as indicating no impairment in the lower extremity. However, documentation and staff interviews confirmed that the resident had significant impairment in the right lower extremity, including limited range of motion and pain, and required substantial to maximal assistance with lower body dressing, transfers, and mobility tasks. Physical therapy staff confirmed the resident's right lower extremity impairment, noting specific limitations in extension and flexion, and occupational therapy records also documented impaired range of motion and pain in the right knee. The MDS Coordinator acknowledged that the resident should have been coded for impairment on one side in the lower extremity section of the MDS. The deficiency was identified through record review and staff interviews, which demonstrated that the resident's functional impairment was not accurately reflected in the MDS assessment.