Failure to Timely Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS system within 14 days of discharge for two residents. For one resident, a male with diagnoses including pneumonia, acute respiratory failure with hypoxia, sepsis, dysphagia, and gastrostomy status, the discharge MDS assessment was 83 days overdue following his discharge. His medical record showed completed entry and admission MDS assessments, but the required discharge assessment was not submitted in the required timeframe. For the second resident, a female with a history of skin transplant, the discharge MDS assessment was 9 days overdue, and the assessment was still marked as 'In Progress' after her discharge with home health services. Her record also showed a completed MDS assessment prior to discharge, but the discharge assessment was not finalized or transmitted as required. Interviews with the Director of Nursing (DON) and two MDS Coordinators revealed that the discharge MDS assessments for these residents were simply missed. The DON stated that review of MDS assessments was handled by corporate staff, not by himself. The MDS Coordinators acknowledged the oversight and indicated the importance of completing discharge MDS assessments for CMS and insurance notification. Facility policy and the RAI Manual both require that OBRA discharge assessments be completed and submitted within 14 days of discharge, which was not followed in these cases.