Inaccurate MDS Assessment for Resident Behaviors and Wanderguard Use
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident in the areas of behaviors, wandering, and the use of a wanderguard bracelet. The resident, who had a history of cerebral infarction, cognitive deficits, and was newly diagnosed with adjustment reaction with aggression, exhibited multiple concerning behaviors during the MDS look back period. These included being combative with staff, physically abusive, exit-seeking, wandering the unit, and causing injury to a roommate. Despite these documented behaviors and the application of a wanderguard bracelet, the 5-day admission MDS inaccurately indicated that the resident was cognitively intact, had no behaviors, and was not using a wanderguard. Interviews with facility staff revealed that the Social Worker Manager did not update the MDS to reflect the resident's behaviors or use of a wanderguard, citing that the incident occurred after he completed his portion of the assessment. However, the MDS Nurse clarified that the look back period included the dates when these behaviors occurred and that any changes during this period should have been incorporated into the MDS. The MDS Nurse acknowledged the omissions and indicated that the MDS should have been marked for wandering, behavioral issues, and wanderguard use. The Administrator noted her absence during the assessment period and believed the MDS would have been completed correctly had she been present.