Failure to Complete and Submit Discharge MDS Assessments
Penalty
Summary
The facility failed to complete and submit discharge Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) database for two residents who were discharged. For one resident, who was admitted for short-term rehabilitation following hospitalization for respiratory failure, pneumonia, and influenza, the medical record showed that discharge planning was conducted and the resident was discharged home with in-home services. However, there was no evidence that a discharge MDS was initiated, completed, or submitted as required. For the second resident, who was readmitted after a hospital stay for an amputation and later transferred to another facility, the documentation included progress notes about the resident's care and discharge process. Although a quarterly MDS and an entry tracking record were completed, there was no discharge MDS completed or submitted after the resident's discharge. Staff interviews confirmed that the required discharge MDS assessments were not completed for both residents, contrary to facility policy and regulatory requirements.