Failure to Complete and Transmit Discharge MDS Assessment Timely
Penalty
Summary
The facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessment for one resident within the required timeframe. Specifically, the discharge MDS assessment for a resident with multiple diagnoses, including chronic systolic heart failure, respiratory failure, hypertension, atherosclerotic heart disease, and unspecified dementia, was not completed or transmitted to CMS as required. The assessment remained open and unfinished after the resident's discharge, and the MDS coordinator acknowledged that it should have been completed by day 14 post-discharge but was unsure why it was overlooked. Interviews with the MDS coordinator, DON, and administrator confirmed that the responsibility for completing and tracking MDS assessments rested with the MDS coordinator, and that monitoring was supposed to occur through scheduled meetings and reports in the facility's electronic system. However, the discharge MDS assessment for this resident did not appear on the in-progress report, and there was no clear explanation for the omission. The facility's policy required comprehensive assessments to be completed and submitted according to CMS guidelines, but this process was not followed in this instance.