Inaccurate MDS Discharge Status Documentation
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident, specifically regarding the resident's discharge status. A review of the clinical record showed that the resident was admitted and later discharged to the hospital. The resident was private pay and chose not to continue private payment to hold their room during the hospitalization, which is a key indicator that the return to the facility was not anticipated. Despite this, the MDS assessment documented the discharge as 'return anticipated' in Section A0310F, which was inconsistent with the resident's payor status and discharge planning information. During an interview, the Registered Nurse Assessment Coordinator acknowledged the inaccuracy in the MDS assessment and confirmed that the discharge should have been recorded as 'return not anticipated.' This discrepancy was identified through a review of the clinical record, the RAI, and staff interviews, indicating that the facility did not accurately reflect the resident's discharge status as required.