Failure to Accurately Assess and Document Resident's Range of Motion Limitation
Penalty
Summary
The facility failed to accurately assess a resident's range of motion (ROM) limitations, specifically regarding the left leg, during three consecutive quarterly Minimum Data Set (MDS) assessments. Despite multiple therapy evaluations and care plans indicating a history of left femur fracture, ongoing ROM impairment, and the need for assistance with mobility and activities of daily living, the MDS assessments consistently documented that the resident had no functional ROM limitations in either leg. This discrepancy was identified through a review of therapy evaluations, care plans, and direct observation, all of which confirmed the presence of a left leg ROM limitation. The resident in question was admitted with significant medical history, including morbid obesity, a healed traumatic fracture, and a history of falls. Therapy records from both occupational and physical therapy documented the resident's need for moderate to maximal assistance with bed mobility, transfers, and lower body care, as well as specific recommendations for active and active assistive ROM exercises to both legs. Observations and interviews with staff and the resident further confirmed the left leg's reduced ROM and ongoing need for restorative interventions. Despite this clear documentation and direct evidence, the MDS assessments failed to reflect the resident's actual ROM limitations, resulting in inaccurate data being entered into the federal database. The MDS Coordinator acknowledged that the assessments were inaccurate and that the information from therapy evaluations should have been incorporated into the MDS to ensure an accurate representation of the resident's condition.