Inaccurate MDS Coding for Resident Discharge Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect the discharge status of a resident who was reviewed for hospitalization. The MDS indicated that the resident was discharged to a short-term general hospital, but nursing progress notes and interviews with staff and the resident confirmed that the discharge was actually to home with medications and instructions provided to family members. Multiple staff, including an LPN, the MDS facility liaison, and the MDS clinician, acknowledged upon review that the MDS was coded incorrectly and did not accurately reflect the resident's actual discharge destination. Facility policy requires that the information captured on the assessment accurately reflects the resident's status during the observation period.