Failure to Complete and Transmit MDS Discharge Assessment
Penalty
Summary
The facility failed to complete and transmit a Minimum Data Set (MDS) discharge assessment for one nonsampled resident who was discharged home. According to the facility's policies and procedures, the MDS nurse is responsible for scheduling and completing all required assessments, including discharge assessments, and ensuring that encoded, accurate, and complete MDS data are electronically transmitted to the CMS system. Review of the closed medical record for the resident showed that although there was a physician's order for discharge and arrangements for home health services and equipment, there was no evidence that the MDS discharge assessment was completed at the time of discharge. During interviews, the MDS Coordinator confirmed that the discharge assessment should have been completed and submitted to CMS within the required timeframe, and acknowledged that the system used by the facility is designed to track due dates for assessments. The MDS Coordinator verified that the discharge assessment was not completed for the resident, and explained that failure to complete and submit the assessment would result in the resident appearing as still present in the facility and the assessment being marked as missed. The Director of Nursing also acknowledged these findings.