Failure to Accurately Assess and Document Resident Wandering Behaviors
Penalty
Summary
The facility failed to accurately identify and document wandering behaviors on the MDS Resident Assessments for one resident with dementia and a known history of daily wandering. Staff responsible for completing the admission MDS assessment did not review the resident's medical diagnoses or fully consider behaviors prior to admission, instead assuming the assessment only pertained to current behaviors observed within the facility. The staff member also did not interview the resident or family members, relying solely on progress notes, which resulted in the omission of the resident's daily wandering behavior from the assessment. The resident's electronic health record indicated a diagnosis of wandering at admission and contained multiple progress notes documenting daily incidents of wandering and exit-seeking from the day of admission onward. Despite this, the admission MDS assessment indicated no wandering behaviors, and the subsequent quarterly MDS assessment understated the frequency of wandering. This inaccurate documentation limited the facility's ability to implement appropriate care plan interventions to address the resident's actual care needs.