Failure to Complete and Submit Discharge Assessments
Summary
The facility failed to ensure that resident assessments for discharge were completed and submitted to CMS for two residents who were reviewed for resident assessments. Resident #68, who was admitted with acute and chronic respiratory failure, diabetes type II, and congestive heart failure, was transferred to the hospital and expired there. A review of the assessment log revealed that a discharge assessment had not been completed or submitted for this resident. MDS Coordinator #1 acknowledged that the discharge assessment was missing because it was an unplanned discharge and was not noted on their calendar. Similarly, Resident #63, admitted with malignant neoplasm of the cervix, chronic kidney disease stage III, and type II diabetes, was discharged to the hospital. The assessment log showed that a discharge assessment for this resident was also not completed or submitted in a timely manner. MDS Coordinator #1 admitted to forgetting to enter the discharge assessment into the system due to the unplanned nature of the hospital discharge.
Penalty
Resources
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The facility failed to electronically transmit MDS assessments for two residents, leading to a deficiency. One resident with metabolic encephalopathy, muscle weakness, and diabetes had a discharge MDS assessment that was not transmitted within the required timeframe. Another resident with diabetes, muscle weakness, and chronic obstructive pulmonary disease also had a discharge MDS assessment that was not transmitted on time. These issues were identified during a survey when the Resident Assessment task flagged MDS assessments over 120 days old.
Failure to Transmit MDS Assessments for Two Residents
Penalty
Summary
The facility staff failed to electronically transmit the Minimum Data Set (MDS) assessments for two residents, leading to a deficiency in the Resident Assessment task. For Resident #8, who had diagnoses including metabolic encephalopathy, muscle weakness, and diabetes, the discharge MDS assessment with an Assessment Reference Date (ARD) of 02/15/24 was not transmitted within the required timeframe. This oversight was identified during the survey process when the Resident Assessment task flagged an MDS that was over 120 days old. Upon review by the Licensed Practical Nurse (LPN) and Registered Nurse (RN), it was confirmed that the assessment had not been transmitted until the day of the survey. Similarly, for Resident #92, who had diagnoses including diabetes, muscle weakness, and chronic obstructive pulmonary disease, the discharge MDS assessment with an ARD of 12/27/23 was also not transmitted within the required period. This issue was similarly identified during the survey process when the Resident Assessment task flagged an MDS over 120 days old. The LPN and RN confirmed that the assessment had not been transmitted until the day of the survey. Both incidents were discussed in a meeting with the facility's administrative and nursing leadership, but no further information was provided to the survey team before the exit conference.
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