Inaccurate MDS Assessments for Resident with Documented Contractures
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately for one resident. The resident was admitted with diagnoses including Parkinson's disease, Alzheimer's disease, and protein-calorie malnutrition, and was assessed as having self-care deficits related to range of motion limitations and contractures of her knees. Despite these documented limitations, the quarterly MDS assessments coded the resident as having no impairment in functional range of motion in both upper and lower extremities. Observations confirmed the presence of bilateral knee contractures and a contracture in the left hand, with adaptive equipment and instructions for use present in the resident's room. Interviews with facility staff revealed that the MDS nurse primarily relied on nursing assessments and the care plan, and did not consistently perform direct assessments of the resident. The MDS Coordinator and DON acknowledged that the MDS assessments were inaccurate, attributing the errors to incorrect coding or misunderstanding of the assessment questions by the responsible nurse. The administrator was unaware of the specific cause of the error but expected assessments to be accurate.