Inaccurate MDS Assessment for Discharged Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) Assessment for a resident, which is a federally mandated standardized assessment used to plan resident care. The deficiency was identified during a review of clinical records and the Resident Assessment Instrument (RAI), as well as through staff interviews. Specifically, the Discharge MDS Assessment for a resident who was admitted on October 28, 2024, and discharged on November 15, 2024, inaccurately indicated that the resident was discharged to a short-term general hospital. However, a discharge nurse's note from the same date revealed that the resident was actually discharged home with her son. This discrepancy was confirmed by the director of nursing during an interview on January 30, 2025.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. MDS for resident # 74 was corrected and submitted at the time of survey. To identify like residents that have the potential to be affected, the MDS Nurse/designee will complete a 14-day look back of section A2105, discharge stats to ensure it is coded correctly. To prevent this from happening again, the Regional Reimbursement coordinator/designee will educate the RNAC on appropriate coding for section A2105 on the MDS. To monitor and maintain ongoing compliance, the RNAC will review all discharges weekly x 4 then monthly x 2 to ensure that Section A2105 is coded correctly. Results will be reviewed at QAPI.