Inaccurate MDS Assessments for Range of Motion and Discharge Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded for several residents. In multiple cases, there were discrepancies between therapy evaluations, provider documentation, and the MDS records. For one resident, therapy evaluations documented impaired range of motion (ROM) in the lower extremity and full ROM in the upper extremities, but the MDS assessments incorrectly indicated upper extremity impairment. Another resident with documented right-hand contractures and provider orders for a contracture management device had MDS assessments that failed to reflect upper extremity limitations and instead incorrectly noted lower extremity impairment. A third resident had consistent therapy documentation of full ROM in both upper extremities, yet the MDS assessments repeatedly recorded functional limitations in the upper extremity. Additionally, a closed record review revealed that a resident who was discharged home was incorrectly coded in the MDS as having been discharged to a short-term general hospital. These errors were confirmed through interviews with staff, including the MDS coordinator, who acknowledged the inaccuracies after reviewing the relevant documentation. The deficiencies were identified through record reviews, interviews, and observations conducted by surveyors.