Inaccurate MDS Assessment Documented Resident Discharge
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident. According to the MDS assessment tool, the resident was documented as discharged to home/community on a specific date. However, review of the resident's care plan indicated that the resident and their responsible party had chosen long-term placement, and progress notes from the relevant period did not document any discharge. Direct observation confirmed that the resident was still present in the facility after the reported discharge date, and staff interviews verified that the resident had not been discharged. The Director of Nursing (DON) acknowledged that the MDS inaccurately documented the resident as discharged and confirmed the resident's continued presence in the facility. The Assistant Director of Nursing (ADON) stated there had been discussions about the resident discharging home, but the family ultimately decided against it. Facility policy requires that qualified staff conduct accurate assessments reflective of the resident's status at the time of assessment, and that each assessor certifies the accuracy of their portion of the assessment. In this case, the assessment did not accurately reflect the resident's status.