Inaccurate MDS Coding for Wandering Behavior and Wander Guard Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected the resident’s behavioral status and use of a wander/elopement alarm. The resident had diagnoses of vascular dementia with behavior disturbances and depression, was cognitively impaired with poor decision-making skills, and had been identified on an elopement risk evaluation as ambulating independently and displaying behaviors that could indicate attempts to leave the facility. The resident’s care plan, initiated on the same date as the elopement risk evaluation, documented that the resident was at risk for wandering/elopement, had been observed near exterior doors, and required a wander guard device on the ankle with placement and function to be checked every shift. A physician’s order also directed that a wander guard device be applied to the resident’s ankle and checked every shift. Despite these documented behaviors and interventions, the annual MDS assessment coded the resident as having severe cognitive impairment (BIMS score 6/15) but no pacing or wandering behaviors, and indicated the resident ambulated independently with supervision using a walker. In Section E (Behavior), the MDS was coded to show delusions but no wandering behaviors, and in Section P (Restraints and Alarms), it was coded to show that no wander/elopement alarm was used. During interview, the DON stated that the resident’s baseline behavior was to always wander up and down the hallways and that the MDS nurse should use assessments, care plans, and progress notes to ensure accurate MDS coding. The DON acknowledged that the MDS did not accurately reflect the resident’s behaviors, and the facility did not provide a specific policy on MDS accuracy, only a general documentation policy stating that nursing documentation must be accurate, timely, complete, and reflective of the care provided.
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