Inaccurate Discharge MDS Coding of Aggressive and Wandering Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge Minimum Data Set (MDS) accurately reflected the presence and frequency of physically aggressive and wandering behaviors during the assessment look-back period. The resident was an elderly male with diagnoses of unspecified dementia and anxiety who was admitted and later discharged to an acute care hospital. His Discharge – Return Not Anticipated MDS coded physical behavioral symptoms toward others as occurring 1–3 days, verbal behavioral symptoms as not exhibited, rejection of care as occurring 1–3 days, and wandering as occurring 4–6 days but less than daily. The Brief Interview for Mental Status (BIMS) was not assessed on this discharge MDS. Progress notes for the days immediately preceding discharge documented frequent and severe behaviors that were inconsistent with the limited frequency captured on the MDS. Nursing and physician notes described the resident as repeatedly attempting to elope, being verbally and physically aggressive (hitting, kicking, biting, head-butting staff, attempting to throw his wheelchair), refusing medications, and engaging in dangerous behaviors such as attempting to smother his roommate with a pillow, flipping a coffee table, attempting to throw a lamp through a window, and banging on windows. Notes also documented that the resident required 1:1 oversight due to behaviors and elopement attempts, with multiple entries indicating ongoing agitation, aggression, and repeated attempts to leave the facility. In interviews, the MDS coordinator stated she was responsible for completing the admission and discharge MDS assessments and that she obtained Section E information from nursing progress and behavior notes. After reviewing the discharge MDS, she acknowledged that Section E did not accurately reflect the behaviors exhibited by the resident during the assessment period and agreed that an inaccurate MDS could affect proper care and provide an inaccurate reflection of residents’ status. An LVN and the DON both reported that the resident exhibited physically and verbally aggressive behaviors multiple times a day, continuously attempted to elope, required constant 1:1 observation, and was a danger to himself, other residents, and staff. The facility’s Comprehensive Assessments policy defined a significant error as one in which the resident’s overall clinical status is not accurately represented on the assessment and has not been corrected by a more recent assessment, aligning with the surveyors’ finding that the discharge MDS did not accurately represent the resident’s behavioral status.
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