Inaccurate MDS Assessment of Wandering Behavior
Penalty
Summary
A deficiency was identified when the facility failed to ensure the accuracy of a resident's Minimum Data Set (MDS) assessment regarding wandering behavior. The resident in question had a history of Alzheimer's disease, anxiety, and dementia, with documentation indicating severe cognitive impairment and an inability to make decisions. Multiple progress notes and care plans described the resident as exhibiting wandering behavior, including entering other residents' rooms and taking their belongings, which required staff intervention and redirection. Despite this documented behavior, the MDS assessment completed for the resident did not indicate any wandering behavior. Interviews with facility staff, including a CNA, the MDS Coordinator Nurse, the Director of Nursing (DON), and the Social Service Assistant (SSA), confirmed that the resident did, in fact, wander and required frequent redirection. The DON and SSA both acknowledged that the MDS assessment was inaccurate and did not reflect the resident's actual behavior. The facility's policy and procedure on the Resident Assessment Instrument stated that each discipline assigned to complete a section of the MDS is responsible for the accuracy of the information. The failure to accurately document the resident's wandering behavior on the MDS assessment was confirmed through record review and staff interviews, resulting in a deficiency for not ensuring the assessment accurately reflected the resident's status.
Plan Of Correction
F641 Corrective action for residents found to have been affected by this deficiency: Resident number 1 was kept safe. Roommate that was involved was moved to another room immediately on 7/7/25. Resident 1 was monitored for any signs and symptoms of emotional distress, none noted. On 8/5/25, MDS consultant gave one-on-one in-service and education to SSA 1 regarding proper and accurate behavioral coding, i.e., resident exhibiting wandering behavior. Corrective action for residents that may be affected by this deficiency: On 8/5/25, MDS coordinator reviewed residents with behavior emphasizing on residents with wandering behavior. None were noted. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not reoccur: On 8/5/25, MDS consultant provided in-service and education training to MDS nurses and Social Services staff in regards to proper and accurate behavior assessment and coding. MDS accuracy will be reviewed by IDT member to ensure behaviors were accurately captured and documented during admission record review and scheduled residents' care conference. MDS consultant will validate compliance twice a month as scheduled. Findings will be reported to DON for follow-up. Measures that will be put into place to ensure that this deficiency does not reoccur: The above POC will be reviewed in the QAPI committee for 3 months and as needed thereafter. Administrator and/or Designee will report trends.