Inaccurate Resident Assessment Documentation
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected their status, specifically regarding wandering behavior and dementia diagnosis. The quarterly Minimum Data Set (MDS) assessment did not document wandering behaviors in Section E, despite other records, such as the quarterly Elopement Wandering assessments, repeatedly listing dementia as a diagnosis for the resident. The resident's face sheet did not include dementia as a diagnosis, and the resident had a BIMS score indicating severe cognitive impairment. The discrepancy between the MDS and other assessments, as well as the inconsistent documentation of dementia, was identified during record review and interviews. During interviews, the DON acknowledged that dementia was incorrectly selected as a diagnosis on multiple Elopement Wandering assessments and admitted to not being aware of her own error in selecting dementia on one of the assessments. The DON also stated that whoever completed the assessment was responsible for its accuracy and recognized that incorrect documentation could affect assessment outcomes. The administrator, lacking a clinical background, also noted that inaccurate information in the electronic record could impact assessment results. Facility policy requires comprehensive and accurate assessments, but this was not followed in this instance.