Incorrect Coding of Discharge Status on MDS Assessment
Penalty
Summary
The facility failed to accurately code a resident's discharge status on the Discharge Minimum Data Set (MDS) assessment. Specifically, a review of medical records showed that a resident was discharged to an Assisted Living Facility (ALF), as documented in the nurse's note, discharge summary by the nurse practitioner, social services note, and physician's order. However, the MDS Discharge Return Not Anticipated (DCRNA) assessment incorrectly coded the discharge status as a transfer to a short-term general hospital (acute hospital) instead of to the community/ALF. Interviews with facility staff confirmed the error. The social worker verified that the resident was discharged to an ALF and described the process for communicating discharge status changes to the interdisciplinary team. The MDS coordinator also acknowledged the resident was discharged to an ALF and that the discharge assessment should have reflected this. The Director of Nursing was notified of the concern.