Inaccurate MDS Coding for Resident Discharged to Hospital
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident who was transferred to the hospital and subsequently died there. The resident, who had a medical history including multiple sclerosis, urinary tract infection, and sepsis, was admitted to the facility and later experienced respiratory distress, prompting a family-requested transfer to the hospital. Documentation showed the resident was transferred to the hospital and later died there. However, the MDS assessment was inaccurately coded as a death in the facility, rather than a discharge to the hospital followed by death at the hospital. Interviews with MDS staff revealed confusion and human error in the coding process. One MDS nurse initially began a discharge assessment, but another nurse changed it to a death assessment based on an incorrect assumption about the resident's place of death. Both MDS staff and the Director of Nursing acknowledged that the assessment did not accurately reflect the resident's discharge location and date of death, resulting in inaccurate data being submitted to CMS.