Inaccurate Discharge Status Assessment on MDS
Penalty
Summary
The facility failed to accurately assess and document the discharge status of a resident as required by the Resident Assessment Instrument (RAI) Manual. The resident, who had diagnoses including orthopedic aftercare, hypertension, atrial fibrillation, and a right artificial knee, was admitted to the facility and had a care plan indicating a potential discharge to a lower level of care. The resident was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. Despite multiple records, including social services and discharge summary notes, indicating that the resident was discharged home with family and home health services, the Minimum Data Set (MDS) discharge assessment inaccurately coded the resident as being discharged to a short-term general hospital. Both the facility administrator and the MDS/LPN confirmed during interviews that the MDS discharge assessment was incorrect and did not reflect the actual discharge destination.