Inaccurate MDS Coding of Range of Motion Limitations for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the range of motion (ROM) limitations for two residents. For one resident, the most recent quarterly MDS assessment did not capture the contracture of her left knee, despite her medical record, care plan, and staff interviews confirming a longstanding contracture and associated interventions such as positioning for comfort and prevention of further contracture. The resident herself reported an inability to straighten her left knee for years, and both the care plan and staff acknowledged the contracture and related care needs. However, the MDS was coded as having no functional limitations to her extremities, based on the MDS nurse's interpretation that the contracture was the resident's baseline normal. For the second resident, the significant change MDS assessment failed to document contractures and ROM limitations on her right side, including her right elbow, hip, and knee, as well as a right below-the-knee amputation (BKA). The resident's care plan addressed only the contracture of her right elbow and did not mention the hip and knee contractures. Observations and staff interviews confirmed the presence of these contractures and the BKA, with care interventions in place for positioning and protection. The MDS, however, was coded as having no impairment in ROM or functional limitation, again based on the MDS nurse's rationale that these conditions were the resident's baseline. Interviews with facility staff, including the former MDS nurse, DON, and Regional Director of Clinical Operations, confirmed that the MDS assessments did not accurately reflect the residents' actual ROM limitations. The staff acknowledged that the inaccurate coding could result in care plans that do not fully address the residents' needs. The facility did not have a specific MDS policy and relied on the RAI manual for assessment and coding instructions.