Failure to Complete and Transmit Discharge MDS Assessment Timely
Penalty
Summary
The facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) database within the required timeframe for one resident. According to the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, a discharge assessment must be transmitted within 14 calendar days of completion. In this case, the resident was admitted and later discharged home with his son, but the discharge MDS remained in-progress and unsigned in the electronic medical record. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the discharge MDS was neither completed nor submitted as required, and the omission was not identified until after the fact. The facility's Resident Assessment Instrument policy did not specify procedures for handling discharge MDS assessments.