Failure to Timely Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure timely transmission of the Minimum Data Set (MDS) assessment to the Centers for Medicare and Medicaid Services (CMS) system for one resident. The resident was admitted and later readmitted with diagnoses including type 2 diabetes, urinary tract infection, and essential hypertension. The resident subsequently expired, and records indicated the body was released and the resident was designated as DNR. A review of the resident's discharge summary and MDS assessment showed that the required discharge MDS was not completed or submitted to CMS as required. During interviews, the MDS Coordinator confirmed that the facility is required to complete and submit the discharge MDS within 14 days of a resident's discharge, but acknowledged that this was not done for the resident in question. The Director of Nursing also confirmed the requirement and noted that the discharge assessment had not been completed or submitted on time. Review of the facility's policy and the CMS RAI User's Manual further confirmed the requirement for timely electronic submission of MDS data within 14 days of the care plan completion or MDS completion date.