Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessment for a resident who expired in the facility. The resident, an elderly female with dementia and Alzheimer's disease, was admitted and later transitioned to palliative care before passing away. Review of her records showed that her last transmitted MDS was the admission assessment, and the required discharge MDS was not completed or submitted within the mandated timeframe. The MDS transmission system indicated that the discharge assessment was 141 days overdue. Interviews with facility staff revealed that the absence of an MDS coordinator contributed to the missed assessment. The Director of Nursing acknowledged responsibility for the oversight and confirmed that the discharge MDS should have been completed and transmitted. The facility's policy and the RAI Manual require timely completion and submission of MDS assessments, including discharge assessments, but these procedures were not followed in this instance.