Failure to Accurately Complete MDS Assessment for Resident with Contracture
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for one resident, as evidenced by the omission of an upper extremity contracture in multiple MDS assessments. The resident, who had diagnoses including Chronic Obstructive Pulmonary Disease and generalized muscle weakness, was observed wearing a palm guard on the left hand. Medical records and physician orders indicated the presence of a left hand contracture, with therapy documentation identifying the contracture as early as August of the previous year. Despite this, quarterly and annual MDS assessments over the past year did not reflect the contracture. Interviews with facility staff, including the Acting Director of Rehabilitation and an LPN, confirmed the longstanding nature of the contracture and that it should have been documented in the MDS. The Director of MDS acknowledged that the contracture was not identified in the most recent MDS and stated that therapy notes should have been reviewed prior to submission. Facility policy requires accurate and timely completion of the MDS by the interdisciplinary team, including nursing and rehabilitation staff.