Inaccurate Resident Assessments Documented
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status and behaviors of two out of three residents reviewed. For one resident with diagnoses including Alzheimer's disease, Parkinsonism, and Bipolar disorder, the quarterly Minimum Data Set (MDS) assessment did not document wandering behavior, despite the resident being a known wanderer, wearing a wander guard, and having a care plan addressing wandering. The MDS Coordinator acknowledged that the omission was likely an error due to a misunderstanding of the criteria for coding wandering behavior. Another resident, with diagnoses such as Peripheral Vascular Disease, Diabetes Mellitus, and Delusional disorder, was care planned for rejecting medications and care, with documented refusals in progress notes. However, the comprehensive MDS assessment did not reflect this behavior, as the MDS Coordinator stated that no outbursts were observed during the look-back period. Both cases demonstrate that the assessments did not align with the residents' documented behaviors and care plans, as required by facility policy and regulatory guidelines.