Failure to Transmit MDS Discharge Assessment Within Required Timeframe
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) discharge assessment record was transmitted within the required 7-day timeframe for one of the sampled residents. According to facility policy, all MDS assessments, including discharge records, are to be completed, encoded, and transmitted to the CMS QIES ASAP system in accordance with OBRA regulations. Record review showed that a resident was discharged on 03/01/25, and while the MDS discharge record was completed, it was not transmitted as required. The MDS coordinator acknowledged that the record had been completed but not exported, attributing the failure to an error on their part. Further interviews revealed that the DON reviewed and signed MDS assessments as they became due but did not monitor whether records had been exported or were incomplete, citing minimal training in the MDS process. The corporate nurse consultant, new to their role, had planned to audit two medical records weekly but indicated a need to reconsider this approach after learning of the missed transmission. The deficiency was identified through record review and staff interviews, confirming the lapse in timely MDS data transmission.