Failure to Accurately Complete MDS and Elopement Risk Assessments for Residents with Dementia
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) and Quarterly Risk Assessments were completed accurately for two residents diagnosed with dementia. Both residents were not properly evaluated for elopement risk, despite documentation indicating they were independently mobile within the facility. The assessments either omitted the elopement risk evaluation or incorrectly stated that the residents were not independently mobile, which was inconsistent with other records and staff observations. For one resident, multiple assessments and interviews revealed discrepancies in documentation regarding mobility and elopement risk. The resident was noted to walk frequently without limitation, yet the elopement risk evaluation was not completed, and the assessment incorrectly indicated the resident was not independently mobile. Staff interviews confirmed that the resident was seen walking throughout the facility, but the MDS nurse misinterpreted the assessment questions and did not consider dementia as a risk factor for elopement. The nurse admitted to using personal judgment rather than following assessment protocols, and the oversight was not caught during supervisory review. A second resident with similar diagnoses also had inconsistent documentation regarding mobility and elopement risk. The resident was described as walking occasionally with no limitation, but the risk assessment was not completed, and the evaluation again incorrectly indicated the resident was not independently mobile. Staff interviews confirmed the elopement risk evaluation was not completed due to a misunderstanding of the assessment criteria. Facility policy required accurate and complete risk assessments on admission and quarterly, but these were not followed, resulting in inaccurate documentation for both residents.