Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) discharge assessment was created and transmitted to the Centers for Medicare and Medicaid Services (CMS) for a resident who was discharged home. The resident had been admitted with diagnoses including urinary tract infection, dysphagia, muscle weakness, and transient cerebral ischemic attack, and was noted to be cognitively intact. Documentation showed that the resident was discharged in stable condition with her family and medications, but review of records and interviews with the MDS Coordinator confirmed that a discharge MDS assessment was not completed or transmitted as required. Facility policy states that MDS data must be encoded and transmitted to CMS within specified timeframes following a resident's discharge. The MDS Coordinator acknowledged that the discharge MDS should have been created on the day of discharge and transmitted within the required period, but this was not done. The last MDS assessment in the system for the resident was a quarterly assessment, and no discharge MDS was present. The Interim Director of Nursing also confirmed that the discharge MDS assessment was not completed or transmitted, which could potentially delay discharge care for the resident.