F0636

E

Failure to Accurately Assess Resident’s Upper Extremity Impairment

Oklahoma City, Oklahoma Survey Completed on 02-18-2026

Penalty

Fine: $50,116

Summary

The deficiency involves the facility’s failure to comprehensively and accurately assess a resident’s physical condition, specifically upper extremity function, as required upon admission and periodically thereafter. Observation on 02/11/26 at 8:48 a.m. showed the resident’s left hand was contracted and completely closed into a fist, with no therapeutic devices in place, and the left arm could not be raised above shoulder height. The resident stated at that time that they had no use of their left hand and could not raise their left arm above their shoulders. A Physician’s Progress Note dated 11/14/25 documented left-sided weakness, and the resident’s admission assessment dated 11/23/25 showed admission with renal failure and heart failure. Despite these findings, the admission assessment documented no impairment to the upper extremities and showed a BIMS score of 14, indicating the resident was cognitively intact.

Further interviews confirmed the discrepancy between the resident’s actual condition and the documented assessment. On 02/12/26 at 9:54 a.m., a CNA reported that the resident was unable to use their left hand and had left arm weakness. On 02/12/26 at 10:38 a.m., the MDS coordinator explained that comprehensive assessment information is collected by reading the chart and personally seeing the patient. When asked, the MDS coordinator acknowledged that the comprehensive assessment did not show any upper extremity impairments and stated that it should have reflected the resident’s left-hand contracture and left arm weakness. The facility had a policy titled Resident Assessments, dated 11/2019, indicating appropriate resident assessments were to be completed, but this was not followed for this resident’s upper extremity status.