Inaccurate MDS Discharge Status Documentation
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of a resident. According to the Resident Assessment Instrument (RAI) User's Manual, Section A2105 requires that the discharge status be coded to indicate the actual location to which a resident is discharged. In this case, a resident with diagnoses of anxiety, hyperlipidemia, and underweight was admitted and later discharged from the facility. The MDS assessment incorrectly coded the resident's discharge status as a transfer to a short-term general hospital, when in fact, the resident was discharged to home/community after the family decided to take the resident out of the facility against medical advice (AMA). Review of clinical records and staff interviews confirmed the error. Nursing progress notes detailed the events leading to the resident's discharge, including the family's decision to remove the resident and the completion of AMA paperwork. The Director of Nursing acknowledged that the MDS was completed incorrectly, with the discharge status and entrance status being flipped, resulting in inaccurate documentation of the resident's actual discharge location.