Inaccurate MDS Discharge Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) discharge assessment was accurately completed for one of seven sampled residents. The resident in question was admitted with multiple diagnoses, including chronic kidney disease, lack of coordination, difficulty walking, a history of falls, and a displaced fracture of the left femur. According to the resident's records, she was discharged to a senior living facility with home health services and accompanied by her family. However, the MDS discharge assessment inaccurately documented that the resident was discharged to a short-term general hospital. Interviews with the MDS Assistant and the Director of Nursing confirmed that the MDS assessment did not reflect the actual discharge destination, as the resident was not sent to a hospital but to a senior living facility. Both staff members acknowledged that the MDS should accurately represent the resident's status at discharge. The facility's policy requires comprehensive and accurate assessments at discharge, including completion of the MDS, but this was not followed in this instance.