Failure to Complete and Transmit Discharge MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that discharge Minimum Data Set (MDS) assessments were completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) database in a timely manner for three residents. According to the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, discharge assessments must be transmitted within 14 calendar days of the MDS completion date. For each of the three residents, documentation showed that they had been discharged from the facility, with corresponding progress notes indicating their discharge status, such as leaving against medical advice, not returning from a leave of absence, or being discharged to another care center. Despite these discharges, the medical records for all three residents lacked evidence that a discharge MDS had been started, completed, or transmitted to CMS, even though several months had passed since their discharge dates. During an interview, the registered nurse responsible for MDS completion confirmed that the discharge MDS assessments for these residents had not been completed, citing issues with the electronic system and missed notifications of resident discharges. The facility was unable to provide a policy on MDS completion when requested.