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 was discharged. The resident, a female with multiple medical diagnoses including nephrostomy catheter infection, congestive heart failure, hypertension, end stage renal disease, and anemia, was admitted and later discharged from the facility. Documentation showed that she was cognitively intact and required substantial assistance with activities of daily living, and had ongoing monitoring for nephrostomy tube output and antibiotic therapy for a urinary tract infection. Upon review, it was found that the discharge MDS assessment for this resident was not documented or transmitted as required. The resident left the facility alert, oriented, and stable, taking all her belongings. Interviews with the DON revealed uncertainty about the resident's discharge destination and indicated that the resident left against medical advice (AMA). The AMA form was signed but not immediately uploaded to the electronic record system, and the discharge order was entered after the resident had already left the facility. Further interviews with the social worker confirmed that the resident left AMA and that the AMA form was obtained but not provided to medical records staff in a timely manner. The facility's policy required documentation of the date and time of discharge, a summary of the resident's condition, and the signature of the person recording the data, but these steps were not fully completed. The lack of a completed and transmitted discharge MDS assessment was confirmed through record review and staff interviews.