Failure to Complete and Transmit Discharge MDS Assessments Timely
Penalty
Summary
The facility failed to meet required timelines for encoding and transmitting Minimum Data Set (MDS) assessments for two residents. Specifically, the Minimum Data Set Nurse (MDSN) did not complete or transmit the discharge MDS assessment for two residents who were discharged from the facility. One resident was discharged to a general acute hospital and did not return, while the other left the facility against medical advice. In both cases, the MDSN acknowledged that the discharge MDS assessments were not completed or transmitted as required by regulations. For the first resident, the clinical record showed admission with diagnoses including asthma, hypertension, and pain. The resident was sent to a general acute hospital and did not return, but the required discharge MDS assessment was not found in the record. The MDSN confirmed that the assessment was not completed within the 14-day requirement following discharge. For the second resident, who had diagnoses of muscle weakness, COPD, and anemia, the record indicated the resident left against medical advice. The MDSN also did not complete or transmit the required discharge MDS assessment within the 30-day timeframe for this resident. Interviews with the MDSN and the Administrator confirmed that it was the MDSN's responsibility to ensure all assessments were opened, completed, and transmitted in a timely manner. Facility policy and job descriptions reviewed during the survey also indicated the expectation for timely and accurate completion of MDS assessments. The failure to complete and transmit these assessments as required constituted a deficiency in the facility's assessment and discharge process.