Inaccurate MDS Coding for Resident with Elopement Risk
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for a resident with a history of elopement and high risk for wandering. The resident, who had dementia and impaired safety awareness, was observed multiple times wearing a wander guard and walking around the facility. Documentation confirmed that the resident had previously eloped from the facility and was subsequently assessed as high risk for elopement, with a care plan and interventions in place, including the use of a wander guard and regular monitoring by nursing staff. Despite these documented risks and interventions, the quarterly MDS assessment did not accurately reflect the resident's wandering behavior or the use of a wander guard. The assessment failed to code for wandering in Section E and did not indicate the use of a wander guard in Section P. This inaccuracy was confirmed by the MDS Coordinator during an interview, acknowledging that the resident's behaviors and interventions were not properly documented in the MDS assessment.