Inaccurate and Incomplete MDS Discharge Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two of three residents whose closed records were reviewed. For one resident, the physician's order and progress notes indicated discharge to a board and care facility under palliative and hospice care, but the MDS assessment incorrectly documented the discharge as a transfer to a short-term general hospital. The MDS Coordinator confirmed this discrepancy during an interview and record review. For another resident, the physician's order showed discharge to home under hospice care, and progress notes confirmed the resident was discharged home. However, the MDS assessment for this resident was found to be incomplete, with the discharge section left blank and not completed. The MDS Coordinator acknowledged that the discharge assessment should have been completed. The Director of Nursing (DON) verified both findings during interviews.