Failure to Timely Complete and Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that the Discharge Minimum Data Set (MDS) assessment was completed and submitted within the required timeframe for one resident. Record review showed that a resident with diagnoses including hypertension, atrial fibrillation, and arthritis was discharged, but the Discharge MDS assessment was not completed and submitted until 122 days after discharge. During an interview, the DON confirmed that the assessment was not completed or submitted in a timely manner and stated that the facility did not have a specific policy for MDS assessment completion, instead relying on the Resident Assessment Instrument (RAI) manual for guidance. According to the RAI User's Manual, a Discharge assessment must be completed within 14 days after discharge and submitted within 14 days of completion, which was not followed in this case.