Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a discharge Minimum Data Set (MDS) assessment for a resident who was admitted with diagnoses including difficulty in walking and hypertension. The resident required partial to moderate assistance with personal hygiene, lower body dressing, and rolling. The resident was discharged home, but the required discharge MDS was not completed or transmitted to CMS within the mandated timeframe. The MDS Coordinator acknowledged forgetting to complete the discharge MDS, which was due within 14 days of discharge. Facility documentation specified that discharge assessments must be completed and encoded within specific timeframes following a resident's discharge. The omission of the discharge MDS assessment resulted in incomplete reporting to CMS and the potential for the resident not to receive necessary care and services, as the resident's health condition and discharge status were not properly updated in the system.