Inaccurate MDS Assessments for Resident with Physical Impairments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately for a resident with significant physical impairments. The resident, who had an above-the-knee amputation of the left leg and a contracted left hand, was repeatedly documented in MDS assessments as having no impairment in upper or lower extremities. Observations confirmed the resident was unable to move the fingers of the left hand, and an occupational therapy evaluation documented contractures and impaired range of motion in the left hand and fingers. Despite these findings, multiple MDS assessments over time, signed by a registered nurse who was not regularly present at the facility, indicated no impairment. The assessments were often completed offsite and based on chart review rather than direct evaluation or input from direct care staff. Interviews with facility staff revealed that the MDS nurse was new and still in training, and the registered nurse responsible for signing the assessments was not physically present at the facility. The regional MDS nurse stated that assessments were completed as chart reviews and justified the lack of impairment documentation by referencing occupational therapy notes that indicated the contracture did not affect functional skills. However, the resident's inability to use the left hand and the presence of an amputation were not accurately reflected in the MDS documentation, despite being longstanding conditions noted in the clinical record and care plan.