Failure to Accurately Document Resident Wandering and Diagnoses
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple complex diagnoses, including heart failure, schizoaffective disorder, insomnia, dysphagia, repeated falls, type 2 diabetes, essential hypertension, muscle weakness, and cognitive communication deficit. Despite the resident exhibiting routine wandering behaviors since admission and an increase in wandering 2-4 weeks prior to a specific date, these behaviors were not documented in the resident's electronic medical record or progress notes. The care plan did not address wandering until a later date, and incident logs did not reflect any wandering incidents. Quarterly Minimum Data Set (MDS) assessments consistently indicated severe cognitive impairment but did not document wandering behaviors or a diagnosis of dementia. However, multiple quarterly elopement risk assessments incorrectly listed dementia as a diagnosis, despite the resident not having this diagnosis according to the MDS and statements from the DON. The DON acknowledged that the incorrect selection of dementia could affect the outcome of risk assessments and that wandering behaviors should have been documented in all relevant assessments and progress notes. Interviews with the DON and Administrator confirmed that the lack of documentation regarding the resident's wandering was an oversight, with the DON attributing it to staff possibly not paying attention or accidentally selecting the wrong diagnosis. Both acknowledged that the responsibility for accurate documentation lay with the staff completing the assessments and that the facility's policies required comprehensive and accurate documentation of resident care, assessments, and behaviors.