Inaccurate MDS Coding for Range of Motion and Mobility Device Use
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for a resident in the areas of range of motion and mobility devices. The resident was admitted with diagnoses including a right tibia fracture, muscle weakness, and physical debility, and had a care plan indicating the need for assistance with ADLs and use of a mechanical lift with two staff for transfers. A Physical Therapy evaluation documented decreased bilateral lower extremity range of motion due to contractures and weakness, limited bed and wheelchair mobility, and the need for the resident’s bilateral lower extremities to be elevated on pillows and leg rests when in a wheelchair. The physical therapist confirmed that the resident’s range of motion was severely decreased and that her legs remained elevated on pillows and leg rests with wheelchair use. Despite these documented impairments and use of a wheelchair, the quarterly MDS assessment coded the resident as having no range of motion impairment in the upper or lower extremities and no use of mobility devices during the assessment period. The MDS Coordinator, who completed the assessment, later acknowledged that review of the Physical Therapy notes showed the resident did have bilateral lower extremity impairment and used a wheelchair as a mobility device, and stated that the MDS had been completed incorrectly. The Administrator also confirmed that the MDS should have been coded to accurately reflect the resident’s range of motion status and mobility device use.
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