Failure to Transmit Discharge MDS Assessment to CMS
Penalty
Summary
The facility failed to electronically transmit an encoded, accurate, and complete Minimum Data Set (MDS) discharge assessment to the CMS system for one resident. Record review showed that the resident was originally admitted with diagnoses including type 2 diabetes mellitus, high blood pressure, and high cholesterol, and was later discharged to their home. The resident's admission MDS assessment was completed, but there was no evidence of a discharge MDS assessment or its transmittal to the CMS system, with the discharge assessment being 116 days overdue. Interviews with the MDS Nurse revealed that the discharge MDS assessment was not completed or submitted due to human error, as the resident left the facility sooner than expected and the process was missed. The Administrator confirmed that the expectation is for the MDS Nurse to process and double-check the discharge assessment for submission to CMS. Facility policy requires assessments to be conducted and transmitted within specified timeframes, but this was not followed in this instance.