by glm777 Member

I have a resident who is s/p CVA with minor cognitive deficits (scored 10 on BIMS). She has had several falls over the past several months. She gets out of bed frequently during the night without assist to go to the bathroom, go to her closet, etc. When reminded that she needs to call for assistance, she says she doesn't need assistance - she denies she is unsteady and states her falls were "accidents". The CNAs are coding this as "wandering " on the flow sheets but I'm not convinced this meets criteria for wandering per the RAI definition. She always has a destination in mind as to where she is going and she actually requires only supervision during the day with ambulation. She easily knows her way around the facility. What do you all think? Can I code wandering for this resident?


Specializes in ER CCU MICU SICU LTC/SNF. 998 Posts

I agree it does not meet the definition. However, an interpretation alone cannot override what's been documented all along. I would confer w/ the IDCP team or the MD. See what is care planned. Staff must be on the same page. What's entered in the MDS must concur with what's documented.