Inaccurate MDS Assessment of Range of Motion
Penalty
Summary
The facility failed to ensure an accurate assessment of range of motion (ROM) for a resident with a history of cerebrovascular accident (CVA) and documented contractures in the left upper and bilateral lower extremities. Despite multiple records, including the admission nursing assessment and history and physical, indicating the presence of contractures, the Minimum Data Set (MDS) assessment did not reflect any impairment in the resident's functional limitation in ROM. The MDS nurse acknowledged that the MDS was inaccurately completed and should have indicated impairment on one side. Observations of the resident confirmed visible contractures and functional limitations, such as the left upper extremity being contracted and the resident's inability to use the left hand due to weakness. The resident also reported numbness and required assistance with repositioning. The facility's policy required comprehensive assessments of residents' physical needs upon admission and at regular intervals, but this process was not followed accurately in this case, resulting in an incomplete and inaccurate MDS assessment.