Inaccurate MDS Coding for Wander/Elopement Alarms
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents who were observed wearing electronic wander/elopement alarm devices as ordered by their physicians and documented in their care plans. Despite the presence of these devices and ongoing orders for their use, the Annual MDS assessments for both residents indicated that the devices were not used. Both residents had severe cognitive impairment, as evidenced by low Brief Interview for Mental Status (BIMS) scores, and were identified as being at risk for elopement or wandering due to dementia and impaired safety awareness. The care plans and physician orders specifically required the use and regular checking of the electronic wandering devices, which were observed in place during the survey. The deficiency was further confirmed through staff interview, where the MDS Coordinator acknowledged that the wander alert devices should have been coded in Section P of the MDS but were omitted due to oversight. Facility policy requires comprehensive and accurate MDS assessments in accordance with federal guidelines, but this was not followed in these cases. The inaccurate coding resulted from a failure to properly document the use of the electronic wander/elopement alarms on the MDS, despite clear evidence of their use and physician orders in the residents' records.