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F0641
B

Inaccurate MDS Coding for Discharge and Hospice Status

Matthews, North Carolina Survey Completed on 12-05-2025

Penalty

Fine: $35,400
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in the areas of discharge and hospice status. For one resident, the discharge MDS was coded as a discharge to home based on information from the responsible party that the resident was sent home from the hospital and would not return to the facility. However, the resident had actually been sent to the hospital for evaluation following an episode of sudden confusion and shaking, and the discharge MDS did not accurately reflect the resident's discharge location from the facility. For another resident with Alzheimer's dementia and rheumatoid arthritis, who was under hospice care, the quarterly MDS assessment was incorrectly coded regarding the resident's prognosis. Although the hospice plan of care and physician documentation indicated a prognosis of six months or less, the MDS was coded as 'no' for this item. The MDS Coordinator acknowledged the error, stating it was a mistake and that the assessment should have been coded correctly.

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