Failure to Timely Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure timely submission of a completed discharge Minimum Data Set (MDS) assessment for one resident. The resident was admitted with diagnoses including spondylosis, stenosis, and type 2 diabetes mellitus, and was later discharged home with home health services and durable medical equipment. Documentation showed that the discharge was initiated by the facility due to improvement in the resident's condition, and all necessary discharge planning steps, such as medication reconciliation and communication with the family, were completed. However, review of the electronic health record revealed that the discharge MDS assessment was not completed or submitted by the Minimum Data Set Coordinator (MDSC), resulting in the assessment being 133 days overdue. Both the MDSC and the Director of Nursing confirmed that the discharge MDS assessment should have been completed and submitted within 14 days of discharge, as required by facility policy and regulatory guidelines. The failure to submit the assessment in a timely manner was identified during interviews and record reviews.