Inaccurate MDS Assessment for Resident Wandering Behavior
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for one resident who was reviewed for accidents. The MDS, which is used to assess behavioral symptoms such as wandering, did not accurately reflect the resident's behaviors during the required 7-day look-back period. Specifically, the MDS indicated that the resident did not exhibit wandering behaviors, despite documentation and staff interviews confirming that the resident had a history of exit-seeking behavior, had wandered to other units, and required a wander guard for safety. The resident had severe cognitive impairment, dementia, and other medical conditions that placed them at risk for elopement, as noted in the care plan and progress notes. Staff interviews, including those with the LPN who documented the wandering and the MDS Coordinator, confirmed that the MDS assessment was not completed accurately and should have indicated the presence of wandering. The Staff Development Coordinator/Infection Preventionist, who was acting as the Director of Nursing, and the Administrator both acknowledged that the MDS was inaccurate and that staff were expected to follow the RAI manual. The deficiency was identified through interviews, record review, and document review, which demonstrated a failure to accurately assess and document the resident's wandering behavior as required.