Failure to Accurately Assess and Code Resident's Range of Motion Limitations
Penalty
Summary
The facility failed to accurately assess and code the Minimum Data Set (MDS) for a resident by not identifying and documenting functional limitations in range of motion (ROM) in both arms. The resident, who had a history of osteoarthritis in the left shoulder and hand, as well as a contracture of an unspecified joint, was cognitively intact and required varying levels of assistance for activities of daily living. Despite these conditions, Section GG 0115A of the MDS was coded as zero, indicating no ROM limitations in both arms, on two separate assessments. Review of the resident's Joint Mobility Evaluations (JMEs) on two occasions showed minimal ROM limitations in both shoulders and severe limitations in both hands and fingers. Observations confirmed the resident was unable to raise both arms to shoulder height or open both hands, with both elbows bent and hands in a fisted position. These findings were inconsistent with the MDS coding, which failed to reflect the resident's actual functional limitations. Interviews with the MDS nurses revealed that they typically relied on input from licensed therapists and compared their assessments with JMEs when coding the MDS. Upon review, both MDS nurses acknowledged that the MDS assessments were incorrectly coded and should have indicated ROM limitations in both arms. The DON also confirmed the importance of accurate MDS coding for appropriate resident care. Facility policy required the resident assessment coordinator to ensure timely and accurate assessments, with all contributors attesting to the accuracy of the information provided.