cms_MS: 75
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
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75 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2017-03-10 | 278 | D | 0 | 1 | U1S311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, facility policy review, and review of the Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, revealed the facility failed to accurately code Resident #5's Minimum Data Set (MDS) related to Range of Motion (ROM) for one (1) of twenty four (24) MDS's reviewed. Findings include: A review of the facility's policy titled, Resident Assessment, dated (MONTH) 1, 2000, revealed the purpose of the resident assessment is to describe the resident's capability to perform daily life function, and to identify significant impairments in functional capacity. A review of the Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual dated (MONTH) (YEAR) in Section Z0400 revealed the person who completes any section or portion of the MDS is required to sign the statement indicating that it is accurate. A review of Resident #5's History and Physical dated 12/14/2016, revealed on the physical examination assessment relating to the extremities, Resident #5 had a bilateral [MEDICAL CONDITION]. A review of the cumulative Physician order [REDACTED]. A review of the Admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 02/02/2017, for Resident #5, revealed section GO400B for Functional Limitation in Range of Motion was coded a zero (0), thus indicating no bilateral lower extremity impairment. During an interview on 03/08/2017 at 3:45 PM, with the MDS Coordinator/Registered Nurse (RN) #2, it was confirmed the Admission MDS with the ARD of 02/02/2017 in Section GO400B for Resident #5 was not coded correctly. RN #2 stated the MDS for Range of Motion (ROM) of the lower extremities should be coded a two (2), thus indicating impairment on both sides. RN #2 confirmed she was the nurse who had completed section G of the MDS, and signed it as being accurate on 02/04/2017. RN #2 also stated the CMS's RAI 3.0 Version Manual, is the policy and guideline used for completing the MDS for the facility. An interview on 03/08/2017 at 3:55 PM, with the Director of Nursing (DON), revealed the Admission MDS with an ARD date of 02/02/2017 was coded incorrectly as relating to the lower extremity impairment. The DON confirmed Resident #5 was a bilateral below the knee [MEDICAL CONDITION]. The DON confirmed the CMS's RAI Version 3.0 Manual was the policy and guideline used by the facility for the MDS completion. A review of the facility's Face Sheet revealed the facility admitted Resident #5 on 01/26/2017, with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/02/2017, revealed the resident's Brief Interview for Mental Status (BIMS) score was fifteen (15) indicating no cognitive impairment. | 2020-09-01 |