Inaccurate MDS Coding for Resident Wandering Behavior
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident when the Minimum Data Set (MDS) was not properly coded. The resident, who had diagnoses of Alzheimer's, dementia, and severely impaired cognition, was assessed on a quarterly MDS with no wandering behavior documented in section E0900 for the seven-day look-back period. However, a progress note from the same assessment reference date indicated the resident had wandered or paced three times during a shift, and an elopement risk assessment identified the resident as at risk for elopement, noting aimless or non-goal-directed wandering. Upon review, the Assistant Director of Nursing (ADON) confirmed that the MDS section E0900 was not accurately coded, as the resident had indeed exhibited wandering behavior during the look-back period.