Inaccurate MDS Coding for Wander/Elopement Alarm Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the use of a wander/elopement alarm for one resident. According to the resident's clinical record, there was a physician's order for an alarming security bracelet to be worn at all times, and treatment administration records showed that staff checked the placement of the bracelet every shift throughout the month. However, the quarterly MDS assessment for this resident was coded as 'Not Used' for the wander/elopement alarm, despite clear evidence of daily use. This discrepancy was confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged that the MDS was incorrectly coded and should have indicated daily use of the alarm. The resident involved had diagnoses including encephalopathy, seizures, and pleural effusion, and had been admitted with these conditions. The failure to accurately code the MDS assessment represents a deficiency in ensuring accurate and complete medical records as required by regulation.