Inaccurate MDS Discharge Status Documentation
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident, as required by the Resident Assessment Instrument (RAI) User's Manual. Specifically, a review of clinical records and the MDS assessment for Resident 106 revealed a discrepancy in the documented discharge status. The MDS assessment indicated that the resident was discharged to a short-term general hospital, while a progress note on the same date documented that the resident was actually discharged to another long-term care nursing facility. This inaccuracy was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the discharge return-not-anticipated MDS assessment did not accurately reflect the resident's actual discharge location.