Failure to Complete and Transmit Discharge MDS Assessment Timely
Penalty
Summary
The facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS system within 14 days after completion for one resident who was reviewed for discharge assessments. Specifically, a female resident who was admitted in September 2024 and discharged in January 2025 did not have a discharge MDS assessment completed or transmitted as required. Review of the resident's MDS assessments revealed that the discharge MDS was more than 120 days overdue at the time of the survey. Interviews with the MDS Nurse, DON, and Administrator confirmed that the MDS Nurse was responsible for completing and transmitting all MDS assessments, including discharge assessments, within the required timeframe. The MDS Nurse acknowledged starting but not completing or transmitting the assessment, and both the DON and Administrator stated their expectation that all MDS assessments be completed and transmitted on time. The facility did not have a specific policy on MDS assessments and referred to the CMS RAI manual for guidance.