Inaccurate MDS Assessments for Discharge Destination and PASRR Status
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents. For one resident with a history of multiple rib fractures, falls, and dementia, the discharge MDS incorrectly documented the discharge destination as a short-term general hospital, when in fact the resident was discharged home with family and home health services. The error was attributed to the Social Services Director (SSD) confusing the resident's discharge location, despite progress notes and care plans indicating the correct destination. The MDS Coordinator and SSD both confirmed the discrepancy during interviews, and the Administrator and Director of Nursing (DON) acknowledged the expectation for accuracy in MDS documentation. For another resident with a history of major depressive disorder, psychotic disorder, bipolar disorder, and generalized anxiety disorder, the annual MDS failed to accurately reflect the resident's Preadmission Screening and Resident Review (PASRR) Level II status, despite documentation from the state confirming its completion. The MDS Coordinator stated that the staff member responsible for the PASRR section did not ensure the information was accurate, and the SSD was unaware of the resident's PASRR Level II status. Both the SSD and DON confirmed the inaccuracy in the MDS coding during interviews.