Inaccurate MDS ADL Coding for Resident With Bilateral Above-Knee Amputations
Penalty
Summary
Surveyors found that the facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident reviewed for Activities of Daily Living. The facility’s policy on MDS assessments, dated March 2025, required comprehensive assessments that describe each resident’s capability to perform daily life functions and identify significant functional impairments. For this resident, the Annual MDS documented a Brief Interview of Mental Status score of 13, indicating intact cognition, and noted bilateral lower extremity impairments, wheelchair use for mobility, and no use of limb prostheses. The same MDS assessment recorded that the resident required substantial/maximal assistance with putting on and taking off footwear, even though other sections documented that sit-to-stand and walking 10 feet were not applicable/not attempted. Record review and interviews established that this documentation did not reflect the resident’s actual status. The resident had diagnoses including orthopedic aftercare following bilateral above-the-knee surgical amputation, type 2 diabetes mellitus, and primary generalized osteoarthritis, and the comprehensive care plan for ADLs identified a self-care deficit related to physical limitations from the bilateral amputations and osteoarthritis. During observation, the resident was seen in bed, stated they did not have legs, and revealed bilateral above-the-knee amputations, further stating they did not use prosthetic devices or footwear. The occupational therapist who completed the Annual MDS confirmed in interview that the resident did not use footwear and acknowledged that documenting a need for substantial/maximal assistance with footwear was incorrect, stating that “not applicable” should have been selected instead. The Director of Rehabilitation and the Director of Nursing Services both stated that the MDS for this resident was not completed accurately and that the assessment should accurately document that the resident did not utilize footwear due to bilateral above-the-knee amputations.
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