Inaccurate MDS Assessments for Hospice and Discharge Status
Penalty
Summary
The facility failed to complete accurate Comprehensive Minimum Data Set (MDS) assessments for two residents out of a sample of 30, as identified through record reviews and staff interviews. For one resident with multiple sclerosis and dementia, who was severely cognitively impaired and had an invoked health care proxy, the facility did not accurately code for hospice services on the MDS, despite the resident having a physician's order for hospice and being admitted to hospice services during the assessment period. The MDS nurse confirmed that hospice services should have been coded but were not, resulting in an inaccurate assessment that did not reflect the resident's status. For another resident with hypertension and atrial fibrillation, the facility failed to accurately code the discharge status on the MDS. The resident experienced an acute change in health status, was unresponsive with abnormal vital signs, and was transferred to the hospital for evaluation. Although the facility expected the resident to return at the time of transfer, the MDS was coded as 'discharge return not anticipated.' The MDS nurse acknowledged that the coding was inaccurate, as the correct code should have been 'discharge return anticipated' based on the circumstances at the time of transfer.