Inaccurate MDS Coding for Resident Discharge Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for one resident. Specifically, the MDS for a resident was coded as a discharge to home/community, while the resident was actually admitted to a hospital and later returned to the facility. The MDS Coordinator, an RN, stated that there was confusion regarding the resident's status after the hospital admission, and the discharge status was incorrectly coded due to a lack of clear information about whether the resident would return. The resident confirmed being hospitalized but was unsure of the exact date. Facility policy requires that all residents receive an accurate assessment reflective of their status at the time of assessment, conducted by qualified staff. The policy defines accuracy as correct documentation of the resident's medical, functional, and psychosocial problems by appropriate health professionals. In this case, the assessment was not accurately coded, as the discharge status did not reflect the resident's actual situation at the time of the MDS assessment.