Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, resulting in a discrepancy in the discharge status. The resident was discharged home, but the discharge assessment incorrectly indicated that the resident was discharged to an acute hospital. This error was identified during a review of the resident's medical records and MDS, which showed a miscode in the discharge status section. The MDS Coordinator, upon reviewing the records, confirmed that the resident had been discharged to their home, contrary to what was documented. The facility's policy and procedure for resident assessments require a comprehensive assessment process to identify care needs and develop an interdisciplinary care plan. However, the miscode suggests a lapse in ensuring the accuracy of the resident's assessment, as the discharge status did not reflect the resident's actual situation.
Plan Of Correction
The Plan of Correction (POC) is submitted as required under federal and state regulations and statutes applicable to long term care providers. This POC does not constitute an admission of liability on the part of the facility and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors findings or conclusions are accurate, that the findings constitute a deficiency or that the scope or severity regarding any of these deficiencies cited are correctly applied. The corrective action accomplished for those residents identified: On Resident #109 Discharge -return not MDS dated was modified and uploaded to IQIES on and accepted. Resident #109 was not negatively affected by the data entry error. No other residents were affected or identified. Other residents having the potential to be affected were identified by: In order to identify any potential residents affected by MDS data entry errors an audit was conducted by the Administrator during, on discharge MDSs for those residents discharged return and return not. The measures of systematic changes made include: MDS Coordinator (Staff B) was reinserviced on, and the additional MDS Coordinator was reinserviced on, regarding the accuracy of MDS coding especially related to discharge residents. In addition, the in-service also reviewed the EMR system and location of information available to assist in accuracy of coding. The Administrator will conduct random audits weekly for 1 month, then monthly for 2 months. The corrective actions put in place include: The Administrator or designee will monitor overall compliance of the MDS accuracy of discharge assessments. Any findings identified will be corrected and reported to the Director of Nursing and QAPI/QAA Committee until substantial compliance is achieved and maintained. The Director of