F0641

D

Inaccurate MDS Coding of ADL Status for Dependent Resident

Edinburg, Texas Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The facility failed to conduct a comprehensive and accurate assessment using the CMS-specified Resident Assessment Instrument (RAI) for one resident. The resident was an elderly female admitted with diagnoses including cerebral infarction due to embolism, osteoarthritis of the left shoulder, and flaccid hemiplegia affecting the left nondominant side. Her significant change MDS assessment showed a BIMS score of 6, indicating severely impaired cognition. In this assessment, her ADLs for chair/bed-to-chair transfer were coded as 88, meaning the activity was not attempted due to medical condition or safety concerns, while sit-to-lying and lying-to-sitting on the side of the bed were coded as requiring substantial/maximal assistance. However, the resident’s care plan documented that she required two staff for chair/bed-to-chair transfers and substantial/maximal assistance with two staff for lying to sitting on the side of the bed and sit to lying.

During interviews and record review, the MDS nurse acknowledged that the code 88 for sit to stand and chair/bed-to-chair transfer was entered in error and stated that the correct code should have been 01, dependent, because the resident required two helpers and was not bedridden. The DON confirmed that the resident liked to sit in her wheelchair during the day, was not bedbound, and that the 88 code on the MDS was incorrect. The DON stated it was the MDS nurse’s responsibility to ensure ADL codes were correct so staff would know the resident’s level of care. Review of the facility’s RAI guidance showed that GG170D (sit to stand) and GG170E (chair/bed-to-chair transfer) should be coded 01, dependent, when two helpers complete all the effort, further demonstrating that the resident’s MDS assessment was not accurately coded for these ADLs.