F0641

D

Inaccurate MDS Coding of Functional Range of Motion

Chicago, Illinois Survey Completed on 11-29-2025

Penalty

No penalty information released

Summary

The facility failed to ensure an accurate MDS assessment by not following the RAI manual for one resident’s functional limitation in range of motion (Section GG0115). The resident, an older adult with diagnoses including personal history of TIA and cerebral infarction, gastrostomy status, adult failure to thrive, essential hypertension, type 2 diabetes mellitus, developmental disorder of scholastic skills, and unspecified asthma, was readmitted with adult failure to thrive and generalized weakness. Hospital discharge records dated 6/26/24 documented limitations in all four extremities, and hospital physician notes from 6/20/24 stated the resident was barely able to move the right arm and was unable to move the left hand or lower extremities. Therapy staff reported providing exercises for the resident’s arms and legs due to weakness and noted more limitation in the left arm and hand.

Despite these documented and observed limitations, the Restorative Nurse, who was responsible for completing the functional limitation in range of motion section of the MDS on 6/30/24, coded the resident as having no limitation in bilateral upper and lower extremities. The Restorative Nurse stated this coding was based on not noticing any limitation during the physical assessment, even though the hospital discharge records reviewed with the surveyor showed limitations in all four extremities. The Clinical Care Coordinator stated it was her expectation that all MDS sections be coded accurately, and the Restorative Nurse job description requires completion of assigned MDS portions accurately and on time. The CMS RAI Manual defines functional limitation in range of motion as limited ability to move a joint that interferes with daily functioning, particularly with ADLs, which was inconsistent with how the resident was coded.