Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a required discharge Minimum Data Set (MDS) assessment for one of two residents reviewed for MDS assessments and transmission. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) Manual, all Medicare and/or Medicaid-certified nursing homes must transmit required MDS data records, including discharge assessments, to the Centers for Medicare and Medicaid Services' (CMS) Internet Quality Improvement Evaluation System (iQIES). The discharge assessment is to be completed no later than 14 calendar days after the discharge date. In this case, a resident was admitted to the facility and later transferred to the hospital, not returning to the facility. Upon review of the electronic health record, it was found that no discharge MDS assessment was completed or transmitted after the resident's discharge. During interviews, the MDS coordinator confirmed that a discharge MDS assessment is typically completed within seven days of a resident's discharge, but acknowledged that no such assessment was completed for this resident and was unsure why it was missed. The deficiency was confirmed through record review and staff interviews, with both the Director of Nursing and the Nursing Home Administrator being informed of the missing discharge MDS assessment. No additional information or explanation for the omission was provided by facility staff.