Inaccurate MDS Discharge Assessment Coding
Penalty
Summary
A deficiency occurred when a resident's Minimum Data Set (MDS) discharge assessment was inaccurately coded and submitted. The resident, who was admitted with diagnoses including weakness and a need for personal assistance, was documented on the MDS as having been discharged to a short-term general hospital. However, review of the resident's medical record revealed no documentation of a hospital transfer, and it was later confirmed by the MDS Coordinator that the resident had actually been discharged to home, not to a hospital. The MDS Coordinator acknowledged during an interview that she had incorrectly coded the discharge status and that the error was present at the time of submission. The Nursing Home Administrator confirmed the inaccuracy of the submitted MDS and stated that the MDS Registered Nurse was ultimately responsible for ensuring the accuracy of the data submitted. The MDS Registered Nurse admitted to only performing spot checks rather than a full review of the assessment before submission, resulting in the inaccurate discharge information being reported.
Plan Of Correction
1. The MDS Nurse appropriately modified and resubmitted the MDS assessment with corrected discharge destination. 2. All residents have the potential to be affected. 3. Bronson Commons MDS RN will double check discharge destination on all assessments prior to signing and submitting to provide a second check of MDS LPN assessments. Policies were reviewed and no necessary updates were identified. 4. The Director of Nursing will complete five weekly audits of discharge location on MDS assessments to ensure accuracy for the next 12 weeks. 5. The Executive Director is responsible for compliance.