Inaccurate MDS Assessments for Functional Limitations and Diagnoses
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in discrepancies between documented assessments and the residents' actual conditions. For one resident with a history of left-sided hemiplegia, hemiparesis, and left hand contracture following a stroke, the MDS was coded to indicate no range of motion (ROM) limitations in both arms. However, the resident's Joint Mobility Evaluation (JME) and direct observation revealed significant ROM limitations in the left arm, including minimal to maximal limitations in the elbow, fingers, and shoulder, and the resident was observed wearing a splint and unable to move the left arm due to paralysis. The MDS nurse confirmed the MDS was coded incorrectly and should have reflected the resident's ROM limitations. Another resident, admitted with right-sided hemiplegia and hemiparesis, had a JME indicating moderate ROM limitations in the right hip, knee, and ankle, and minimal limitations in the left knee. Despite this, the MDS was coded as having no ROM limitations in both legs. Observation confirmed the resident was unable to actively move both legs, and the MDS nurse acknowledged the coding error, stating the MDS should have indicated ROM limitations in both legs. The Director of Nursing also confirmed the importance of accurate MDS coding for appropriate care assessment. A third resident, with diagnoses including dementia and major depressive disorder, was not accurately represented on the MDS, which failed to list dementia as a diagnosis and did not indicate the resident was receiving antipsychotic medication, despite physician orders and medication administration records showing ongoing use of Seroquel for psychosis. The MDS nurse and Director of Nursing both confirmed these omissions, noting that the resident's condition and medication use were not captured in the MDS, contrary to facility policy requiring comprehensive and accurate assessments.