F0641

E

Inaccurate MDS Coding of Mechanical Lift Use for Multiple Residents

Van Alstyne, Texas Survey Completed on 01-31-2026

Penalty

Fine: $21,645

Summary

Surveyors identified a deficiency in which the facility failed to ensure that comprehensive MDS assessments accurately reflected the use of mechanical lifts for eight residents out of twenty-nine reviewed. For multiple residents with diagnoses such as muscle weakness, unsteadiness of feet, lack of coordination, repeated falls, multiple sclerosis, contractures, and muscle wasting, the corresponding Comprehensive MDS Assessments did not indicate that mechanical lifts or sit-to-stand devices were being used, despite other evidence that these devices were part of their care. The MDS Nurse stated she did not code the use of mechanical lifts because she did not see physician orders for these devices, even though she acknowledged that the MDS is a tool to identify resident care needs and provide an overall picture of the resident.

For one resident with moderate cognitive impairment and a history of falls, the Comprehensive MDS Assessment did not show mechanical lift use, and the care plan referenced adaptive equipment for ADLs without specifying the transfer aid. The resident reported that some staff transferred her using a machine and that she had used it the previous year. Another cognitively intact resident with muscle weakness and lack of coordination had a care plan intervention specifying assistance with transfers via mechanical lift as needed, but the MDS did not reflect mechanical lift use and there was no physician order for a mechanical lift. A third cognitively intact resident with similar diagnoses had a care plan directing transfer with a Hoyer lift to a wheelchair; however, the MDS did not indicate mechanical lift use and there was no physician order, even though the resident described being transferred with a machine and surveyors observed CNAs using a Hoyer lift and sling to transfer her.

Additional residents with severe or moderate cognitive impairment, repeated falls, muscle weakness, unsteadiness of feet, lack of coordination, multiple sclerosis, contractures, and muscle wasting also had Comprehensive MDS Assessments that did not indicate mechanical lift or sit-to-stand use. Their care plans either did not specify the type of transfer aid or did not include Hoyer lift interventions, and physician orders for mechanical lifts or sit-to-stand devices were absent. One resident reported beginning to use a sit-to-stand device when his legs became weaker, and surveyors observed CNAs transferring him with a sit-to-stand machine, yet his MDS did not reflect this mode of transfer and there was no corresponding order. The facility’s written policy on comprehensive assessment required gathering relevant information from multiple sources, including observation, physical assessment, and resident interview, to conduct comprehensive assessments and develop person-centered care plans, but the assessments reviewed did not accurately capture the residents’ actual transfer methods involving mechanical lifts.