Inaccurate Resident Discharge Assessment
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident's status for one of the 24 residents reviewed. Specifically, for Resident 58, the discharge Minimum Data Set (MDS) assessment inaccurately indicated that the resident was discharged to an acute hospital. However, a review of the clinical record, including the discharge/transfer summary dated December 5, 2024, revealed that the resident was actually discharged home on that date. This discrepancy was confirmed during an interview with the RNAC, Employee E4, on January 9, 2025, at 11:50 a.m., who acknowledged that the MDS assessment was marked incorrectly.
Plan Of Correction
Upon review of MDS assessment for Resident 58, discharge location was marked in error on Discharge MDS Assessment of Resident 58. Correction was immediately made ("hospital to home") and resubmitted on January 9, 2025, while the surveyor was onsite. RNAC will run "Discharge Register" from EMR on a monthly basis to conduct an audit of discharge MDS and death trackers to confirm accuracy of discharge location. Findings of the audit will be included in the monthly Quality Assurance Documentation Committee report and reported at the quarterly Quality Assurance Committee meeting.