Inaccurate MDS Assessment Coding for Discharge
Penalty
Summary
The facility failed to complete an accurate comprehensive assessment for a resident with Alzheimer's disease, schizoaffective disorder, and intermittent explosive disorder. The resident was admitted with a high risk for elopement, aggression, and required close supervision in a secured unit. Due to the closure of the secured unit, the resident and family were given a 30-day notice for discharge, as the resident's needs could not be met on the main floor. The discharge was scheduled and anticipated, with the family involved in planning and arranging for the resident's personal items to be moved. Despite the planned nature of the discharge, the Minimum Data Set (MDS) assessment was coded as an unplanned discharge by the RN, based on the discharge occurring a day later than originally scheduled. Interviews with staff confirmed that the delay was due to logistical reasons related to moving the resident's belongings, not due to an acute medical event or an unexpected decision by the resident. The Centers for Medicare and Medicaid Services (CMS) guidelines define an unplanned discharge as one resulting from an acute medical need or an unexpected departure, which did not apply in this case. This misclassification resulted in an inaccurate assessment for the resident.