Inaccurate MDS Discharge Coding for Resident Discharged Home
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident who was discharged home with home health services. The MDS was incorrectly coded to indicate that the resident had been transferred to an acute hospital, which did not reflect the actual discharge disposition. This error was identified during a review of the resident's records, which included an admission for cellulitis of the right lower limb and depression, physician orders for discharge home with home health, and progress notes confirming the resident left the facility in stable condition to go home. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the discharge status was inaccurately documented in the MDS. The MDS Coordinator acknowledged the mistake and stated that the discrepancy was not noticed until pointed out by the surveyor. The Director of Nursing also confirmed the inaccuracy in the documentation. The CMS Resident Assessment Instrument (RAI) Manual requires that MDS discharge assessments accurately reflect the resident's discharge location and care needs, which was not met in this instance.