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F0641
D

Inaccurate MDS Coding for Elopement Prevention Device

Warwick, Rhode Island Survey Completed on 06-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the Minimum Data Set (MDS) Assessment accurately reflected the status of a resident assessed as an elopement risk. Record review showed that the resident, who had diagnoses including mild cognitive impairment and muscle weakness, was readmitted to a semi-secure unit and had a care plan in place requiring the use of a TekTONE elopement prevention bracelet. Despite this, quarterly MDS assessments did not indicate the presence of the TekTONE bracelet in the Restraints and Alarms section. During interviews, the MDS Coordinator acknowledged the resident wore the bracelet and admitted it was not accurately coded in the MDS, and the DNS was unable to provide evidence that the device was documented in the assessment.

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