Failure to Complete Timely Discharge and Readmission MDS Assessments
Penalty
Summary
The facility failed to complete a discharge with return anticipated Minimum Data Set (MDS) and a readmission MDS within seven days for a resident who was transferred to the hospital and subsequently returned. Review of the resident's records showed that after experiencing chest tightness, tachycardia, and elevated temperature, the resident was sent to the hospital. Documentation confirmed the resident's hospital transfer, but staff did not complete the required discharge MDS for this event. When the resident returned from the hospital several days later, there was also no readmission MDS completed as required. Interviews with facility staff revealed that the Social Services Director was responsible for certain MDS sections, while the MDS Coordinator, who was new to the role, was responsible for completing the discharge MDS. The Administrator acknowledged that a discharge with return anticipated MDS should have been started once the resident was out of the building for 24 hours, and both the Administrator and DON confirmed that the required MDS assessments were not completed in a timely manner. The facility was unable to provide a policy related to MDS assessments during the review.