Failure to Transmit MDS Discharge Assessments Timely
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) discharge assessments in a timely manner for two residents, resulting in the potential for inaccurate tracking of discharges. Resident #82 was discharged on 9/19/2024, but her MDS discharge assessment, with an assessment reference date (ARD) of 9/20/2024, was incomplete and not transmitted. The sections GG, J, M, N, O, and P were still in progress. Similarly, Resident #93 was discharged on 9/17/2024, and her MDS discharge assessment, with an ARD of 9/17/2024, was also incomplete and not transmitted, with section K still in progress. During an interview, MDS nurse D confirmed that the discharge assessments for both residents should have been completed and transmitted by specific dates in October 2024.
Plan Of Correction
Element 1: MDS discharge assessment for residents #82 and #93 were completed and transmitted. Element 2: Residents that discharge from the facility have the potential to be affected. The last 6 months of discharges have been reviewed for MDS completion and transmission. Identified concerns were addressed at time of observation. Element 3: MDS Nurses have been re-educated on encoding and transmitting data requirements of CMS. Element 4: Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Director of Nursing or designee(s) will conduct random weekly audits of discharge MDS completion and submission. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element #5: The Administrator is responsible for sustained compliance.