Inaccurate Coding of Discharge Status on MDS Assessment
Penalty
No penalty information released
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Summary
The facility failed to ensure that the assessment accurately reflected a resident's status, as evidenced by the case of one resident who was admitted with diagnoses including unspecified combined systolic and diastolic heart failure. The resident's care plan included active discharge planning with the intention to return to the community, and a physician's order was documented for discharge home with home health services. However, the Discharge Minimum Data Set (MDS) assessment was incorrectly coded as an unplanned discharge instead of a planned discharge. This error was confirmed during an interview and record review with the staff member responsible for completing the MDS assessment.