Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code a resident's Minimum Data Set (MDS) assessment according to the Resident Assessment Instrument (RAI) guidelines. Specifically, a resident who was admitted with diagnoses including an intracapsular fracture of the right femur and lobar pneumonia was discharged home with family, as documented in the physician's orders and nursing notes. However, the MDS was coded as a discharge to a short-term general hospital with a status of 'discharge return not anticipated,' which did not reflect the actual discharge destination. During the survey, the MDS Coordinator confirmed that the MDS was incorrectly coded after reviewing the resident's records and acknowledged the error in the presence of the surveyor. The RAI manual specifies that discharges to a private home or community setting should be coded differently, and the facility's documentation supported that the resident was discharged home, not to a hospital. This discrepancy was identified through interviews, record reviews, and examination of facility documentation.