Inaccurate Coding of Resident Discharge Status on MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s assessment accurately reflected the resident’s discharge status. Review of the Discharge MDS assessment for Resident #92, with an ARD of 12/10/2025, showed the resident was coded as having been discharged to a short-term general hospital. However, nursing notes documented that on 12/10/2025 at 11:20 a.m., the resident left the facility via wheelchair using his own transportation. In an interview, the MDS nurse (S9MDS) confirmed that the resident had left the facility against medical advice and that the Discharge MDS was inaccurately coded, stating it should have indicated a discharge to home/community instead of to a hospital. The DON (S2DON) stated he expected MDS nurses to complete all assessments to accurately reflect each resident’s discharge status. This inaccurate coding of the discharge location for Resident #92 on the Discharge MDS constituted the identified deficiency in ensuring accurate resident assessments.
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