Inaccurate Discharge MDS Due to Omitted Discharge Destination
Penalty
Summary
Facility staff failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident when the discharge MDS did not include the resident’s discharge destination. The resident had been admitted with Guillain-Barre syndrome, epilepsy, and depression, and was later unable to transfer out of bed and was sent to the hospital via ambulance for evaluation after experiencing abdominal pain. Record review showed a Change in Condition form and progress note documenting the transfer to the hospital, and the DON stated the resident had been scheduled for discharge on the same day the resident was sent to the hospital. However, the discharge MDS for that resident, completed by the MDS Coordinator, was left with the discharge destination field blank, despite the MDSC acknowledging that the resident was discharged to the hospital and that the assessment was therefore inaccurate. This deficiency was identified through record review of the face sheet, Change in Condition form, progress note, and discharge MDS, as well as interviews with the DON and the MDSC, who confirmed that the discharge destination should have been coded and that it was her responsibility to complete accurate MDS assessments.
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