Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a discharge tracking assessment for one of five sampled residents. Specifically, a resident who was admitted with diagnoses of pyelonephritis and chronic respiratory failure with hypoxia was discharged from the facility, but the required Minimum Data Set (MDS) discharge tracking assessment was not completed or transmitted within the mandated 14-day period following discharge. This was confirmed during an interview and record review with the MDS nurse, who acknowledged that the assessment was not done as required. Review of the facility's policy and procedure indicated that the Resident Assessment Instrument (RAI) process, which includes the MDS, must be completed timely and accurately for all residents, including at discharge. The policy specifies that the discharge MDS assessment is due within 14 calendar days of the discharge date. The failure to complete and transmit the discharge assessment was a direct violation of this policy and federal requirements.