Late Submission of Discharge MDS Assessment
Penalty
Summary
The facility failed to transmit a resident's Discharge Minimum Data Set (MDS) assessment within the required timeframe for one sampled resident. The resident was admitted with a right tibia fracture and required supervision or assistance with most activities of daily living, while maintaining intact cognition. The Discharge MDS had an Assessment Reference Date (ARD) of 2/24/2025 and was completed on 3/10/2025. According to facility policy and federal requirements, the MDS should have been transmitted within 14 days of completion, but it was not submitted until 6/17/2025. During interviews and record reviews, the MDS nurse confirmed the late submission and acknowledged the correct timeframes for completion and transmission. The Director of Nursing also stated the importance of timely submission to ensure CMS has accurate records of resident discharges. The facility's policy, last reviewed in January 2025, aligns with the required assessment and transmission timeframes, but was not followed in this instance.