Inaccurate Resident Assessment Coding
Penalty
Summary
The facility failed to ensure accurate coding of resident assessments, specifically for a resident with a cognitive communication deficit. The resident was noted to have severe cognitive impairment and exhibited wandering behaviors, as documented in behavior and nurse's notes. However, the admission assessment did not reflect these wandering behaviors, indicating a discrepancy in the resident's assessment. The MDS coordinator acknowledged the oversight, noting that the assessment should have included the resident's wandering behaviors during the look-back period. The coordinator reviewed the resident's records and confirmed that the behaviors were present but not coded in the assessment. The individual responsible for the initial assessment was no longer employed at the facility, which may have contributed to the oversight.