Inaccurate MDS Coding for Range of Motion with Contractures
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident with significant contractures and quadriplegia. Observations revealed that the resident had curled fingers on the right hand, contractures in the left wrist, and both ankles, and was unable to move both hands and legs. Interviews with the resident confirmed the inability to open fingers or hold objects due to joint restrictions, and no movement in both legs. The resident's medical history included quadriplegia and cerebrovascular disease, with occupational therapy notes and physician documentation confirming impaired range of motion (ROM) in both upper and lower extremities due to contractures. Despite this, the resident's MDS assessment indicated no impairment for upper or lower extremity ROM. Interviews with the Director of Rehabilitation and the MDS Coordinator confirmed the presence of contractures and impaired ROM, and acknowledged that the MDS assessment was inaccurately coded. The facility's policy requires comprehensive and accurate assessments of each resident's functional capacity, but this was not followed in this case, resulting in an inaccurate MDS assessment for ROM.