Inaccurate Assessment of Range of Motion in Resident
Penalty
Summary
The facility failed to accurately assess a resident for limitations in range of motion. Review of the resident's electronic health record showed discrepancies in the Minimum Data Set (MDS) assessments over several periods. Initially, the MDS indicated no impairment in upper and lower extremities, but subsequent assessments coded impairments on both sides. Interviews with staff revealed that the resident was able to assist with turning on his right side, suggesting that the coding of impairments on both sides may not have been accurate. The MDS coordinator confirmed that, upon review, there was a coding error in the most recent assessment, where impairment should have been recorded on only one side rather than both. This deficiency was identified through record review and staff interviews, which highlighted inconsistencies between the resident's documented functional abilities and the MDS coding. The inaccurate assessment placed the resident at risk of not receiving proper treatment to maintain range of motion, as the documentation did not reflect the resident's actual physical capabilities at the time of the assessment.