Inaccurate MDS Coding for Resident Discharge Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was accurately coded to reflect the actual discharge status of a resident. Specifically, the MDS for one resident indicated a discharge to a short-term general hospital, while both the resident's progress notes and nursing progress notes documented that the resident was discharged home to an assisted living facility and had signed onto hospice care. This discrepancy was identified during an interview and document review, where the MDS coordinator confirmed the MDS was inaccurately coded and did not match the resident's actual discharge destination. The director of nursing also acknowledged that the MDS was expected to be accurate and that MDS coordinators are required to follow the MDS Resident Assessment Instrument (RAI) manual. The manual specifies that accurate assessments must be based on information from multiple sources, including the resident's medical record and direct care staff, and must reflect the resident's actual status during the observation period. In this case, the failure to accurately code the MDS assessment was confirmed by both the MDS coordinator and the director of nursing.