Inaccurate MDS Discharge Coding for Resident Transfer
Penalty
No penalty information released
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Summary
A deficiency occurred when the facility failed to accurately code the Minimum Data Set (MDS) discharge assessment for one resident. The resident, who had a medical history including traumatic subdural hemorrhage and a femur fracture, was admitted from a short-term general hospital and later discharged to an assisted living facility (ALF). Despite documentation in the physician's discharge summary and social services note confirming discharge to the ALF, the MDS discharge assessment was incorrectly coded to indicate discharge to a short-term general hospital. The error was acknowledged by the MDS and Care Plan Coordinator, who confirmed the resident was discharged to an ALF as planned.