Incorrect Coding of MDS Discharge Assessment
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status for one resident reviewed for MDS assessment accuracy. Specifically, the discharge MDS assessment for a male resident with chronic combined heart failure was incorrectly coded as 'return not anticipated' instead of 'return anticipated.' The resident was readmitted to the facility from the hospital within the required timeframe, which should have prompted a 'return anticipated' discharge assessment rather than a new admission assessment. The MDS Coordinator, who was responsible for completing the assessment, acknowledged after reviewing the resident's records that the incorrect assessment type was selected and that it should have been modified to reflect the correct status. Interviews with facility staff, including the MDS Coordinator, Regional Reimbursement Nurse, and Administrator, confirmed that the correct assessment was not completed and that there was no specific policy or procedure in place regarding MDS assessment accuracy, with staff relying on the RAI manual for guidance. The error was identified through record review and staff interviews, and it was noted that the correct assessment is important for ensuring continuity of care and an accurate plan of care upon the resident's return.