Inaccurate MDS Coding for Resident Discharges
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents whose records were reviewed. For one resident, the MDS indicated the individual died in the facility, but review of the electronic medical record and staff interview revealed the resident was transferred to a hospital by EMS and died there, with no documentation supporting an in-facility death or transfer. For another resident, the MDS coded the discharge as a transfer to a short-term general hospital, but nursing progress notes and staff interviews confirmed the resident was actually discharged to an assisted living facility with his son, not to a hospital. The facility's MDS Completion Guideline had not been updated, reviewed, or revised since its original date.