Inaccurate MDS Coding for Resident Discharge Status
Penalty
Fine: $91,3504 days payment denial
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's discharge status. Record review showed that the resident was admitted and later discharged from the facility, with the MDS coded as a discharge to a short-term general hospital. However, review of emergency transfer logs did not show the resident being sent to a hospital, and progress notes indicated the resident left the facility against medical advice (AMA) to go home. Interviews with the Social Services Director, Administrator, and Director of Nursing confirmed that the resident left AMA to her own home and was not transferred to a hospital, and that the MDS was incorrectly coded.