Inaccurate MDS Assessment of Discharge Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's discharge status. This deficiency was identified during a recertification survey conducted from March 24, 2025, to March 31, 2025. Specifically, the MDS assessment for a resident with unspecified diagnoses inaccurately documented the resident as being discharged to an acute hospital, whereas nursing and social services notes indicated that the resident was discharged home in stable condition, accompanied by family. Interviews with a registered nurse and the MDS Coordinator confirmed that the resident was indeed discharged home, and the error in coding was acknowledged by the MDS Coordinator.
Plan Of Correction
Plan of Correction: Approved April 24, 2025 The facility recognizes the importance of accurate and timely completion of all Minimum Data Set (MDS) assessments, as per regulatory standards and our internal policy titled Minimum Data Set 3.0 (last reviewed 10/2024). Upon review of the discrepancy regarding Resident #358’s discharge status, the following corrective and preventive measures have been implemented: 1. Immediate Correction: The MDS for Resident #358 has been corrected on 3/31/2025 to reflect the accurate discharge destination to home on 03/03/2025. 2. Staff Re-education: The MDS Coordinator received immediate re-education regarding proper discharge coding procedures and the importance of cross-referencing interdisciplinary documentation. 3. Ongoing Compliance: As part of our Quality Assurance and Performance Improvement (QAPI) program, the Director of MDS will audit five (5) discharge assessments every 4 weeks for 6 months to ensure accurate coding of discharge location and identify any additional training needs. The facility remains committed to maintaining compliance with all applicable federal and state regulations and ensuring accurate resident assessments to support appropriate care planning and transitions. Please consider this letter as our formal acknowledgment and assurance that corrective actions have been taken to address the cited concern.