Failure to Complete Timely Discharge MDS Assessments
Penalty
Summary
The facility failed to complete a Discharge Minimum Data Set (MDS) assessment for one resident who was discharged, as required by the Resident Assessment Instrument (RAI) Manual. The manual specifies that a Discharge MDS assessment must be completed within 14 days of discharge for all types of discharges, including those to a private residence. Record review showed that the resident was admitted and later discharged, but the required Discharge MDS was not completed within the mandated timeframe. Additionally, a review of the facility's current MDS assessments revealed that 36 assessments were not completed within the required time frames. Interviews with two RN MDS Coordinators confirmed that the Discharge MDS for the discharged resident was still in progress and overdue. The coordinators acknowledged that they were behind on completing assessments, even with the assistance of remote staff. It was confirmed that three MDS Coordinators share the responsibility for timely completion of MDS assessments, and that the facility follows the RAI Manual as policy. The deficiency was identified through staff interviews, record review, and examination of the facility's MDS assessment records.