Inaccurate MDS Coding for Range of Motion Impairments
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents, resulting in discrepancies between the documented range of motion (ROM) impairments and the residents' actual physical abilities. For one resident, the MDS indicated limited ROM in the lower extremities and no impairment in the upper extremities, while observation revealed a contracture in the left hand and inability to flex the fingers. Another resident's MDS inconsistently documented one-sided impaired ROM across multiple assessments, despite staff interviews confirming that the resident had upper and lower extremity impaired ROM and was totally dependent on staff for activities of daily living since admission. A third resident's MDS documented one-sided impairment for ROM to upper and lower extremities, but both staff interviews and direct observation showed that the resident could move both arms and legs, assist with feeding, and hold a coffee cup unassisted. The MDS Coordinator acknowledged misunderstanding the definition of impaired ROM when coding previous MDS assessments. The facility's policy requires accurate and thorough assessments per MDS guidelines, but these requirements were not met for the residents involved.