F0641

D

Inaccurate MDS Coding of Bed Mobility Assistance Needs

Arverne, New York Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment for a resident. The facility’s policy on Resident Assessment, last reviewed on 10/25/2025, required comprehensive and accurate assessments using direct observation and communication with residents and direct care staff on all shifts. The resident, admitted with dementia, seizure disorder, and COPD, had a Comprehensive Care Plan effective 02/03/2026 documenting dependence for bed mobility (rolling left to right) with a need for total assistance of two staff. However, the MDS assessment dated [DATE] coded the resident’s bed mobility as requiring only Partial/Moderate assistance, indicating the helper did less than half the effort, which did not match the care plan or the resident’s actual needs.

During observation on 03/11/2026 at 9:00 AM, the resident was seen receiving total assistance from two staff for bed mobility. In interviews, an RN stated on 03/10/2026 that the resident required total care with two people for bed mobility and turning/positioning, and a CNA reported that two staff had been providing total assistance for bed mobility since the resident’s readmission. The Director of Rehabilitation stated that the rehab department completed the MDS bed mobility section (GG0130), that the resident was on skilled therapy and required total care with assistance of two people for bed mobility and transfers, and acknowledged that the MDS coding was in error and should have been “dependent” rather than “partial/moderate.” The MDS Coordinator reported that they typically collect information from assessments, staff interviews, and medical record review and double-check records for accuracy before submitting MDS assessments, but stated they were not aware of the discrepancy in this resident’s MDS dated 02/12/2026.