Inaccurate MDS Discharge Assessment Coding
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the resident's status for one resident whose Minimum Data Set (MDS) records were reviewed. Specifically, the Discharge MDS assessment for this resident was incorrectly coded, indicating that the resident was discharged to a short-term general hospital, when in fact, documentation and staff interviews confirmed the resident was discharged home with family. This discrepancy was identified through review of the resident's face sheet, progress notes, and staff interviews, which consistently indicated the resident's actual discharge destination was home, not a hospital. The resident involved had a medical history including type 1 diabetes mellitus with ketoacidosis, major depressive disorder, and anemia. The error in the MDS assessment was acknowledged by both nursing staff and the facility administrator during interviews, who confirmed that the coding did not match the resident's actual discharge status as documented in the clinical record.