Failure to Timely Code Discharge to MDS
Penalty
Summary
The facility failed to ensure that a discharge was coded to the Minimum Data Set (MDS) in a timely manner for one resident. The resident had medical diagnoses including vertebra and humerus fractures and malnutrition, and was transported from the facility to a local hospital via ambulance. The discharge MDS assessment, which should have been completed within 14 days of discharge as required by the Resident Assessment Instrument (RAI) manual, was not completed and signed until several months after the resident's discharge. Interviews with the MDS Nurse, Regional MDS Consultant, and MDS Trainer confirmed that the discharge was not reported within the required timeframe. The MDS Nurse acknowledged the delay, and the Regional MDS Consultant stated there was no system in place to track unreported discharges. The MDS Trainer noted that discharges are typically tracked through the MDS scheduled tab and discussed in daily meetings, but in this case, the tab was erased, resulting in the missed assessment.