Failure to Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to encode and transmit required Minimum Data Set (MDS) discharge assessments within 14 days after discharge for two residents. For one resident, who had diagnoses including congestive heart failure, peripheral vascular disease, and acute respiratory failure with hypoxia, there was no discharge MDS assessment completed or transmitted as of several months after discharge. This resident's care plan included discharge planning interventions, and records indicated he was to be discharged home with family and provider services. For the second resident, who had diagnoses of muscle weakness, depression, and hypertension, and was cognitively intact, there was also no discharge MDS assessment completed or transmitted after discharge to a private home or apartment. This resident's care plan included a focus on returning home with supportive care and services. Interviews with facility staff, including the Director of Clinical Reimbursement (DOCR), Director of Nursing (DON), and Administrator (ADM), confirmed that the discharge MDS assessments were not completed for these two residents. The DOCR acknowledged the missing assessments and was unsure why they were not completed, noting that the responsible staff member was no longer available. The DON and ADM were unaware of the missing assessments until the time of the interview and recognized that the assessments had not been completed or submitted as required.