Inaccurate MDS Coding for Range of Motion Limitations
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the functional status and range of motion (ROM) limitations for two residents. For one resident with a history of left pubic bone fracture, acute pain due to trauma, falls, and difficulty walking, the admission record and physical therapy notes documented significant lower extremity impairment and dependence in mobility and ambulation. However, the MDS section GG0110 was incorrectly coded to indicate no upper or lower extremity ROM limitations, which was inconsistent with the clinical documentation. The Director of Nursing (DON) confirmed the coding error during a review. For another resident admitted after surgery for circulatory system issues, including a recent thromboembolectomy and ongoing lower extremity vascular problems, the admission record and hospital discharge summary indicated lower extremity impairment. Despite this, the MDS section GG0110 was coded as showing upper extremity impairment and no lower extremity impairment. Upon review, the DON and Assistant Administrator acknowledged that the coding did not accurately reflect the resident's condition, as the resident had no upper extremity limitations but did have lower extremity ROM impairment on one side. The facility's policy required MDS assessments to be completed according to the MDS 3.0 RAI User's Manual, but this was not followed in these cases.