MDS Coding Error 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 information. The resident, who was initially admitted from a Short-Term General Hospital with a medical diagnosis of other specified injuries, was scheduled to be discharged to an Assisted Living Facility (ALF). However, the MDS was incorrectly coded to indicate that the resident was discharged to a Short-Term General Hospital instead of the ALF. The error was identified during a review of the resident's clinical records and discharge assessment. The discharge assessment MDS reference indicated a planned discharge, but the section for discharge status incorrectly coded the resident as being discharged to a hospital. This was contrary to the nurse's notes, which documented that the resident was discharged to the ALF and transported via wheelchair. During an interview, the MDS Coordinator acknowledged the error, explaining that the Social Services department is responsible for inputting discharge information, while the MDS department verifies the timely submission of this information. The coordinator accepted responsibility for the error on behalf of the department. The facility's policy requires a complete admission observation/assessment to develop a care plan tailored to the resident's needs, with ongoing assessments throughout the resident's stay.
Plan Of Correction
Immediate Action: The Minimal Data Set dated for sample resident #200 was modified for discharge status to an Assisted Living Facility in section A 2105 on was resubmitted on. Responsible staff member was re-educated on accurate Minimal Data Set completion by the MDS Nurse. Identification of Residents with potential to be affected: All residents that are discharged have the potential to be affected. The discharge assessment- return not and return MDSS completed since will be audited for discharge location accuracy and modified per Resident Assessment Instrument Manual. Inaccuracies identified will be corrected and resubmitted. System Changes: All resident discharges will be discussed by the Interdisciplinary Team on the next business day to determine discharge disposition. Discharges will be completed by the MDS Nurses in the entirety as of. Monitoring: Monthly audits of all Discharge Assessments will be audited weekly for accuracy for the next 3 months. An audit sheet will be maintained to demonstrate accurate completion of section A2105. Results will be reported monthly to the Quality Assurance Performance Improvement committee. At the end of 3 months, the Quality Assurance Performance Improvement Committee will reassess the need for ongoing audit frequency and duration. Responsible Party: MDS Nurses/ Coordinators