Inaccurate MDS Assessments for Wandering Behavior
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the residents' status, specifically regarding wandering behavior. This deficiency was identified during a recertification survey for two residents. Resident #37, diagnosed with Non-Alzheimer's Dementia, Anxiety Disorder, and Mood Disorder, was documented in the MDS assessments as not exhibiting wandering behavior, despite evidence to the contrary. The resident's care plan included interventions for wandering, and observations noted the resident at the facility's entrance, indicating a risk for elopement. Interviews with staff confirmed that the resident occasionally attempted to leave the facility, contradicting the MDS assessment. Similarly, Resident #130, with diagnoses of Non-Alzheimer's Dementia, Malnutrition, and Depression, was also inaccurately documented in the MDS assessment as not exhibiting wandering behavior. The resident's care plan and evaluation notes indicated a history of wandering and the need for constant redirection. Observations during the survey showed the resident wandering off the unit and requiring staff intervention. Staff interviews corroborated these observations, highlighting the resident's frequent wandering and need for engagement in activities to prevent such behavior. The MDS Coordinator, responsible for completing the assessments, stated that wandering behavior was not documented if it was not observed during the assessment period. This approach led to inaccuracies in the MDS documentation for both residents, as their wandering behaviors were evident through care plans, staff observations, and interviews. The facility's policy on comprehensive assessments did not specifically address the accuracy of the assessments, contributing to the deficiency.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 Immediate Correction 1) On 12/30/24, The Minimum Data Set (MDS) Coordinator reviewed and updated the Quarterly MDS assessment to accurately document Resident #37’s wandering behavior. 2) On 12/30/24, The Comprehensive Care Plan for Resident #37 was reviewed and revised by the MDS Coordinator to ensure interventions accurately reflect their current wandering status, including additional monitoring and activities to reduce wandering episodes. 3) On 12/30/24, The Quarterly MDS assessment for Resident #130 was reviewed and updated to reflect their wandering behavior accurately. 4) On 12/30/24, The Comprehensive Care Plan was updated by the MDS Coordinator to ensure alignment with observed behaviors, including enhanced monitoring and interventions to address wandering tendencies. 5) On 12/30/24, Education Counseling was conducted and completed on Accuracy of Assessments for the MDS Coordinator, DON, ADON, DSW, and DOR. Identification of Others 1) An audit of the last 30 days of MDS assessments will be conducted by the MDS Coordinator to identify any inaccuracies related to wandering or other behaviors. 2) Residents identified with discrepancies will have their MDS assessments updated, and care plans revised accordingly. Systemic Changes 1) The facility policy on Minimum Data Set Comprehensive Assessments has been revised by the Administrator to include explicit guidelines emphasizing the importance of accurate documentation of residents’ behaviors, including wandering. 2) All MDS Coordinators, Registered Nurses (RNs), and Licensed Practical Nurses (LPNs) will be re-educated on: - A review of the regulatory requirement of F641. - The importance of accurate MDS documentation. - Observing, reporting, and documenting wandering and other behavioral patterns. - Utilizing interdisciplinary team input to ensure MDS accuracy. 3) A daily communication audit tool will be developed and implemented to ensure all wandering behaviors are documented and considered during MDS assessments. Quality Assurance (QA) 1) An interdisciplinary team meeting will be held bi-weekly to review residents with identified wandering behaviors and ensure care plans and interventions are appropriate and effective. 2) Monthly in-service training sessions on MDS accuracy and behavioral documentation will be conducted to ensure ongoing compliance x 6 months. 3) Audits will be completed by the MDS Coordinator weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 4) Findings will be brought to the QAPI meeting quarterly for tracking of facility compliance. Person Responsible for this Ftag: 1) The MDS Coordinator.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident with diabetes had quarterly MDS assessments that incorrectly coded insulin use despite current orders showing weekly semaglutide injections and no insulin orders. The resident stated she did not receive insulin, and an RN confirmed the MDS was coded incorrectly and needed modification. The DON stated the MDS should accurately reflect each resident’s status.
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident’s quarterly MDS failed to code use of a non-invasive ventilatory device, even though a BiPAP machine was observed at bedside and the resident stated staff assisted with it at night. The chart also included orders for CPAP/BiPAP use for OSA, and the MDS coordinator confirmed the assessment was coded incorrectly.
A facility failed to accurately code MDS assessments for code alert device use for multiple residents identified as at risk for elopement and wandering. Although a wander guard log showed several residents had code alert devices, the MDS often stated the devices were not in use and did not reflect wandering behavior. Several care plans also lacked elopement or wandering interventions, and staff interviews confirmed the MDS should reflect code alert placement because it drives the care plan.
Inaccurate MDS Coding for Insulin: A resident’s quarterly MDS was coded to show insulin use during the lookback period, but review of the physician’s orders and MAR found no evidence the resident received insulin. An LPN confirmed the assessment was coded inaccurately.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Inaccurate MDS Coding for Diabetes Medication
Penalty
Summary
The facility failed to accurately code medication on the Minimum Data Set (MDS) assessment for 1 resident who was reported to be receiving insulin. The resident had a diagnosis of diabetes, and the quarterly MDS assessments accepted on 2/3/26 and 4/15/26 identified that the resident received an insulin injection 1 time during the last 7 days. However, the resident’s current physician orders showed no insulin orders. Instead, the orders included semaglutide, with instructions for a weekly subcutaneous injection on Wednesdays for diabetes with hyperglycemia, beginning at 0.25 mg and then increasing to 0.5 mg. During interview, the resident stated she did not receive insulin and instead received a weekly GLP-1 injection on Wednesdays. The RN confirmed she had incorrectly coded both quarterly MDS assessments as the resident receiving no insulin and stated she would need to complete and submit a modification of the assessment. The DON stated she would expect the MDS to be accurate and reflect each resident’s status.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
MDS Incorrectly Omitted BiPAP Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident who used a non-invasive ventilatory device. The resident’s quarterly MDS dated [DATE] identified intact cognition with no hallucinations or delusions, but in Section O, the item for non-invasive mechanical ventilator use, including BiPAP and CPAP, was not checked, and Section Z1, “none of the above,” was marked instead. During observation, a BiPAP machine was seen on the resident’s bedside table with a gallon of water next to it, and the resident stated staff assisted with the machine at night. The resident later stated she had previously used CPAP and had been changed to BiPAP. The medical record included an order to resume CPAP with home settings and an after-visit summary documenting BiPAP home use with specified pressure settings for obstructive sleep apnea. An LPN stated staff assisted the resident with a CPAP machine, and the MDS coordinator confirmed the quarterly MDS was coded incorrectly because the resident did use a non-invasive ventilatory device.
Inaccurate MDS Coding for Code Alert Devices
Penalty
Summary
The facility failed to ensure accurate MDS coding for the use of code alert devices for 14 of 14 residents identified as at risk for elopement and wandering. The code alert system log titled Wander Guard Monitor for 4/2026 identified residents R3, R4, R12, R13, R17, R18, R19, R22, R25, R28, R32, R34, R37, and R46 as having a code alert device in use, but their MDS assessments did not consistently reflect that information in Section P. Instead, the assessments frequently indicated that a wander guard alarm was not in use and that the residents had not exhibited wandering behavior. Several resident records also lacked corresponding care plan interventions for elopement and wandering. R3, R4, R18, R22, R28, R32, R34, R37, and R46 had care plans that did not include elopement or wandering interventions, and R22's care plan did not identify the placement location of the code alert device. R37's problem area for elopement was not initiated until 5/1/26. R46 was discharged on 4/20/26, and the care plan was requested but not received. R19's most recent elopement assessment identified low risk and included clothing labeled with identification and an identification band, but did not select the door alarm band applied as an intervention. R12's assessments similarly identified low risk and listed clothing labeling and an identification band, but did not select the door alarm band applied. The record also showed inconsistencies between assessments, documentation, and staff statements. R13 and R17 had elopement assessments completed on 5/1/26 and their code alert devices were removed, while R19's EMR lacked evidence that elopement assessments were completed quarterly. R12's EMR lacked evidence of quarterly elopement assessments, and progress notes stated the assessments were reviewed with no change despite later documentation of a successful exit of the building and attempts to exit. During interviews, staff stated that residents with wandering or elopement risks should be identified on the care plan, that code alert devices were kept in a book at the main entrance desk, and that the MDS should be coded to reflect code alert placement because it drives care and the care plan.
Inaccurate MDS Coding for Insulin
Penalty
Summary
Resident 2’s quarterly MDS dated March 22, 2026, was coded to indicate that the resident received insulin on one day in the last seven days in section N0350. However, review of the physician’s orders and the MAR showed no evidence that the resident received insulin during the assessment lookback period. During interview on April 23, 2026, at 1:35 p.m., licensed staff E4 confirmed that the assessment was coded inaccurately.
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