Inaccurate Discharge Assessment for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of assessments regarding a resident's discharge status. Specifically, for Resident 105, a discharge MDS dated February 3, 2025, inaccurately indicated that the resident was discharged to a hospital. However, further review of the clinical records, including a discharge summary from the same date, revealed that the resident was actually discharged to home. This discrepancy was identified during a clinical record review and confirmed through interviews with the resident and staff. The issue was discussed with the Nursing Home Administrator and Director of Nursing on April 10, 2025.
Plan Of Correction
This Plan of Correction is submitted under Federal and state regulations and status applicable to long-term care providers. This Plan of Correction does not constitute an admission of liability on the part of the facility and such liability is hereby denied. The submission of this Plan of Correction does not constitute agreement by the facility that the surveyor's findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope and severity regarding any of the deficiencies are cited correctly. Please accept this plan as our credible allegation of compliance. Discharge MDS for Resident 105 was corrected on 4/10/2025. Discharge MDS' completed over the last 30 days will be reviewed to ensure accuracy of section A2105. Assessment Coordinators will be re-educated on ensuring the accuracy of assessments prior to submission. An audit of discharged MDS will be completed monthly for 3 months to ensure accuracy. Results of this audit will be reviewed by the Quality Assurance Committee to evaluate the need for ongoing auditing or further education.