Inaccurate MDS Coding for Wandering and Falls
Penalty
Summary
The deficiency involves inaccurate resident assessments documented in the MDS for two residents. For one resident with chronic kidney disease and dementia, the clinical record showed an elopement risk assessment completed on November 21, 2025, identifying the resident as at risk for elopement. The care plan documented the resident as at risk for elopement with an elopement monitor applied to the right ankle, and physician orders included an active order for an elopement bracelet starting the same date. A nursing progress note dated November 26, 2025, at 9:50 PM described exit-seeking behaviors, including attempts to get outdoors, looking for keys, and wandering. Despite these documented behaviors and interventions, the MDS dated November 27, 2025, coded Section E0900 (Wandering – Presence & Frequency) as 0, indicating that wandering behavior was not exhibited during the look-back period. In an interview, the Nursing Home Administrator acknowledged that this MDS was coded inaccurately and should have captured the resident’s wandering behavior. The second resident had diagnoses including dementia and anxiety and experienced multiple falls. The clinical record documented a fall on October 23, 2025, with no injury; a fall on November 3, 2025, resulting in skin tears to the right forearm and elbow; and a fall on December 9, 2025, resulting in a bruise on the top of the right hand measuring 6.5 cm by 6.5 cm. However, the MDS for this resident coded Section J1900 (Number of Falls Since Admission/Entry or Reentry or Prior Assessment) as two or more falls with no injury and one fall with injury. In an interview, the Nursing Home Administrator stated that this MDS was also coded inaccurately and should have reflected two falls with injury and one fall with no injury. These discrepancies between the clinical records and the MDS coding demonstrate that the facility failed to ensure that resident assessments accurately reflected the residents’ actual status, in violation of 28 Pa. Code 211.5(f) Clinical records and 28 Pa. Code 211.12(d)(3)(5) Nursing Services.
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