Inaccurate MDS Coding for Resident Wandering Behavior
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for a resident was accurately coded to reflect the resident's wandering behavior. The resident, who had diagnoses including severe dementia with behavioral disturbance, schizophrenia, major depressive disorder, and bipolar disorder, was observed multiple times roaming the facility in a wheelchair. The resident's Medical Administration Record indicated at least ten episodes of roaming daily, and both Certified Nursing Assistant and Licensed Vocational Nurse interviews confirmed that the resident wandered around the facility and required frequent redirection. Despite these observations and documentation, the MDS assessment did not indicate that the resident exhibited wandering behavior. Both the LVN and Registered Nurse acknowledged during interviews that the MDS assessment was inaccurate and should have been coded as occurring daily. The Assistant Director of Nursing confirmed that the MDS nurse was responsible for completing and auditing the MDS assessments, and the facility's policy required that assessments accurately reflect the resident's status during the observation period.