Failure to Accurately Complete and Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that the discharge Minimum Data Set (MDS) 3.0 assessment for one resident was completed accurately and that a correction was submitted in a timely manner to reflect the resident's actual discharge disposition. The resident, who had multiple diagnoses including hypertension, cognitive communication deficit, depression, polyneuropathy, chronic pain, dementia, GERD, benign prostatic hyperplasia, acquired absence of the right leg above the knee, and schizoaffective disorder, was admitted on 06/17/19. On 03/02/25, the resident was transported to a local hospital by critical transport, and the power of attorney was notified. The discharge MDS assessment completed on the same day was coded as 'discharge - return anticipated' and marked as an unplanned discharge. However, documentation indicated that the resident was discharged to the hospital with the intention of going home on hospice services, meaning the discharge should have been coded as 'return not anticipated.' No correction to the MDS assessment was completed at the time to accurately reflect this disposition.