F0842

D

Inaccurate Dementia Diagnosis Documentation and Mismanaged Elopement Risk Records

Dallas, Texas Survey Completed on 02-06-2026

Penalty

Fine: $12,740

Summary

The deficiency involves the facility’s failure to maintain complete, accurate, accessible, and systematically organized medical records for a male resident with a history of cerebral infarction, osteoarthritis, schizophrenia, depression, anxiety, and documented dementia. The resident’s admission MDS showed a BIMS score of 13 (cognitively intact) with an active diagnosis of non‑Alzheimer’s dementia and no wandering behaviors. His clinical history and a Mental Illness/Dementia Resident Review signed by the MD indicated a dementia diagnosis, and the MD attested on 11/11/2025 that the resident had a primary or dementia diagnosis. The care plan initiated in October and revised in late November documented impaired cognitive function/dementia, use of Donepezil for dementia, and psychiatric diagnoses, as well as risk for falls and safety concerns related to leaving the facility without notice.

Despite these records, on 11/27/2025 the RNC struck out dementia as a primary diagnosis from the resident’s medical diagnoses, and the diagnosis no longer appeared on the face sheet. The RNC reported she discontinued the dementia diagnosis based on the resident’s high BIMS score and nursing assessments, after a verbal conversation with the MD, but she did not document this conversation or any justification for changing the medical record. The MD confirmed he approved discontinuation of the dementia diagnosis after being informed of the BIMS score, but he was not aware of the resident’s exit‑seeking behaviors or elopements, and there was no documentation of those behaviors in his or his NP’s notes. At the same time, the resident continued to be care planned and medicated for dementia, and psychiatric notes documented cognitive impairment symptoms, including decreased concentration, forgetfulness, difficulties with ADLs, disorientation to situation, and unreliable history.

The facility also failed to accurately and consistently complete and document the resident’s elopement risk evaluations. Progress notes described multiple episodes of exit‑seeking and elopement, including the resident going to the facility gate wanting to go home, two elopement episodes leading to transfer to a psychiatric hospital with police involvement, and an incident where he independently left and checked himself into a local hospital. Staff interviews (LVN, RN, previous SW) described the resident as an elopement risk, with behaviors such as exit‑seeking, frequent talk of leaving, digging under the fence, and requiring 1:1 monitoring. However, elopement risk evaluations on 11/02/2025 and 11/27/2025 were locked as “No Risk,” and staff only completed the “No Risk” section despite triggers for moderate or imminent risk. These evaluations contained internal discrepancies regarding the resident’s ability to make decisions and ambulate, and the care plan revised on 11/27/2025 did not reflect the documented elopement attempt and actual elopements on 10/24/2025, 11/02/2025, and 11/27/2025. The DON and ADM acknowledged the importance of accurate records and documentation of physician notifications and elopements, but the facility’s records for this resident remained inconsistent with his diagnoses, behaviors, and treatment.

The facility’s own Medical Record Content policy required accurate, timely, and complete records that support diagnoses, justify medical necessity, and facilitate continuity of care, including consistent assessments and progress notes aligned with care plans and documented physician notifications and orders. In this case, there was no documentation of the physician order or rationale to discontinue the dementia diagnosis, no integration of the PASRR/MD‑signed dementia attestation into the record review, and incomplete elopement risk assessments that did not match the resident’s documented behaviors and staff observations. These inconsistencies resulted in a medical record that did not accurately reflect the resident’s active diagnoses, dementia treatment, or elopement risk status as required by facility policy and accepted professional standards.

The DON stated that residents with high BIMS scores or who could make decisions were not considered elopement risks, and that if a resident had dementia but could make decisions, they were not an elopement risk. This view contrasted with other staff who identified the resident as an elopement risk regardless of his BIMS score. The administrator also stated that the resident was not an elopement risk because of his high BIMS score and lack of dementia, and he asserted that certain nursing notes about elopement were not accurate. These differing interpretations and the lack of consistent documentation contributed to the inaccurate and incomplete medical record for the resident, including the discrepancy between the discontinued dementia diagnosis and ongoing dementia‑related care and medications, as well as the under‑documented and misclassified elopement risk.