Inaccurate MDS Assessment of Lower Extremity Range of Motion
Penalty
Summary
Facility staff failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident, specifically regarding the assessment of lower extremity functional range of motion. The resident's MDS assessments with assessment reference dates of 2/19/25 and 11/19/24 documented impairment in both lower extremities, which was inconsistent with other MDS assessments for the same resident that indicated no functional limitations. The resident was assessed as able to make self understood and to understand others, with a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe cognitive impairment. During the survey, the Administrator-in-Training was unable to provide documentation supporting a decline in the resident's lower extremity functional range of motion as recorded in the MDS assessments. The discrepancy in the MDS documentation was identified through observation, staff interviews, and clinical record review, revealing that the assessments did not accurately reflect the resident's actual condition at the time.