Inaccurate MDS Coding for Rejection of Care and Wandering Behaviors
Penalty
Summary
Facility staff failed to ensure accurate coding of Minimum Data Set (MDS) assessments for two residents, specifically related to rejection of care and wandering behaviors. One resident with multiple diagnoses including CVA, hemiplegia, COPD, and muscle disease was documented on 12/24/25 as alert, oriented, verbally responsive, and refusing lab work, with the MD and representative notified and the lab rescheduled. The resident’s care plan was revised the same day to address noncompliance with treatment and care, with interventions such as leaving and returning later and providing education. However, the admission MDS, which included a BIMS score of 08 indicating moderate cognitive impairment, was coded to show that rejection of care behaviors were not exhibited, despite documentation of refusal of care during the 7‑day lookback period. The MDS Coordinator later acknowledged that rejection of care should have been coded based on the available documentation. Another resident with anemia, CKD stage 3, Alzheimer’s disease, and BPH experienced an episode of altered mental status and seizure activity, was found nonresponsive, and was transported to the hospital by EMS. Upon readmission, the resident was assessed as alert, verbally responsive, and oriented to person. A subsequent Significant Change MDS showed a BIMS score of 03, indicating severely impaired cognition, and was coded in Section E to reflect wandering behaviors occurring 4–6 days in the lookback period and placing the resident at significant risk of reaching a potentially dangerous place. Observations showed the resident seated in a Geri chair in the day room, alert to self only, with staff sitting next to him and reporting that he was not ambulatory and required supervision to prevent falls. Review of progress notes and the TAR for the month showed no documentation of wandering behaviors, and the unit manager stated the resident had not wandered for at least a couple of months. The MDS Coordinator reported that Section E was completed by the social worker, who later confirmed that the wandering behaviors were coded based on a past history rather than current behavior and acknowledged this was a mistake.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.