Inaccurate MDS Discharge Coding for Resident
Penalty
Summary
The facility failed to ensure the accurate coding of a resident's discharge destination in the Minimum Data Set (MDS) assessment. Specifically, a resident who was admitted with diagnoses including hyperlipidemia and type 2 diabetes mellitus was discharged home per their request after dialysis treatment. However, the MDS assessment incorrectly documented the discharge destination as a short-term general hospital. This error was identified during a review of the resident's admission record, physician's order, and discharge summary, all of which confirmed the resident was discharged home. Interviews with the MDS Coordinator and the Assistant Director of Nursing confirmed that the resident was not discharged to a hospital, and both acknowledged the necessity for accurate MDS coding. The facility's policy and procedure on the MDS and Resident Assessment Instrument (RAI) process indicated that all members of the Interdisciplinary Team share responsibility for the accurate completion of the RAI, with the RN MDS Coordinator responsible for reviewing and signing off on the assessment. Despite these procedures, the MDS was not coded accurately, resulting in incorrect information being reported to CMS.