Inaccurate MDS Coding for Smoking and Elopement Alarm
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident in the areas of smoking and elopement alarms. The resident, who had diagnoses including dementia without behavioral disturbances and bipolar disorder, was assessed as requiring supervision while smoking and had a care plan updated to reflect this status. Additionally, there was a physician order and documentation for a wander guard (elopement alarm) device, with corresponding care plan interventions for elopement risk. Despite these documented needs and interventions, the MDS admission assessment did not reflect the resident's tobacco use or the use of a wander/elopement alarm. Observations and interviews confirmed the resident was a smoker and was wearing a wander guard device. The MDS Nurse acknowledged missing the coding for tobacco use and wander guard, stating she did not see the order for the wander guard and overlooked the tobacco use section during assessment coding. The Administrator confirmed that the MDS Nurse was responsible for ensuring the accuracy of the resident's assessment coding.