Inaccurate MDS Assessment for Resident with Mobility Impairments
Penalty
Summary
Facility staff failed to complete an accurate quarterly Minimum Data Set (MDS) assessment for one resident. The resident, who had diagnoses including paraplegia, atherosclerotic cardiovascular disease, and neuromuscular dysfunction of the bladder, was coded in the most recent MDS as having no cognitive impairment and being dependent for bed mobility, transfer, hygiene, and required supervision for eating. However, the MDS also indicated no impairment in lower extremity range of motion and that walking 10 feet was not attempted due to medical or safety concerns. The resident's care plan identified risks for falls related to muscle weakness, poor balance, and psychoactive medications, with interventions such as ensuring the resident wore shoes when ambulating and keeping items within reach. During staff interviews, an LPN recalled that the resident could not walk and used a wheelchair, and the MDS coordinator acknowledged errors in the MDS coding for functional limitations and mobility. The MDS coordinator stated that the RAI manual is the standard used for completing the MDS. The director of nursing, administrator, and assistant director of nursing were informed of these findings. The deficiency was identified through review of facility documents, clinical records, and staff interviews.