Inaccurate MDS Discharge Documentation
Penalty
Summary
The facility failed to accurately document a resident's discharge plan on the Minimum Data Set (MDS) assessment. Review of the resident's care plan and progress notes indicated that the resident wished to be discharged to their home, specifically to their assisted living apartment. Multiple entries in the medical record, including nursing, social services, and restorative program notes, confirmed that the discharge to assisted living was planned and communicated to the resident and their family. The resident's therapy was concluded, and a home exercise program was provided in preparation for the discharge. Despite this clear discharge plan, Section A of the MDS assessment completed on the discharge date was marked as 'return anticipated,' indicating the resident was expected to return to the facility. During an interview, the MDS Coordinator acknowledged responsibility for completing this section and, upon review, admitted that 'return not anticipated' should have been selected based on the resident's actual discharge plan. The coordinator explained that she often selects 'return anticipated' for residents who frequently return, but recognized this was not appropriate in this case.