Failure to Transmit Required Discharge MDS: The facility did not timely transmit a required Discharge MDS for a resident who was transferred to the hospital and did not return. Surveyors reviewed the resident’s record and MDS submissions and found no Discharge MDS had been sent. The MDSC confirmed the Discharge-Return Anticipated MDS was not completed or transmitted when the resident left the facility.
Failure to transmit a resident’s death MDS assessment to CMS occurred after the RN/MDS coordinator completed the assessment but did not hit the complete button. The DON and ADON stated only three staff had access to transmit MDS assessments, and they were not aware the assessment needed transmission because it was not completed in the system.
MDS assessments were not completed or transmitted timely for multiple residents, including entry tracking, quarterly, modification to quarterly, and discharge assessments. Survey review of the EHR found missing accepted transmission dates or accepted dates outside the required window, and the Regional Nurse-D confirmed the assessments were completed or transmitted incorrectly.
A resident with metabolic encephalopathy, pneumonia, and HTN was discharged to the hospital due to a change in condition, but the discharge MDS was not completed and was documented as late. The MDS Coordinator said the omission was an oversight.
A resident was discharged to the hospital after worsening pain, abnormal vital signs, decreased responsiveness, and oxygen use. The resident’s DCRA MDS was completed but not submitted to the State within the required timeframe, and review of submitted batches showed it was not included.
A required discharge MDS assessment was not completed or transmitted for a resident who was transferred to the hospital and did not return. Review of the electronic health record and staff interviews confirmed the omission, with the MDS coordinator unable to provide a reason for the oversight. Both the DON and NHA were notified of the missing assessment.
Failure to Complete and Transmit Discharge MDS Assessment: A resident admitted with non-traumatic brain injury was discharged to the hospital, but the discharge MDS was not completed or transmitted as required. During record review, the MDSC confirmed the assessment should have been done and stated the completion timeline was 7 days.
A resident’s discharge MDS was not transmitted in the required timeframe. The assessment was created and later transmitted, then unsubmitted, and no final discharge MDS was sent. The DON/RN stated there had been a change in staff completing the MDS and acknowledged the discharge MDS should have been transmitted.
The facility did not encode and transmit a resident’s assessment data to the State within the required 7-day period following assessment, as identified through record review.
The facility did not encode and transmit a resident’s assessment data to the State within the required 7-day period after assessment, as evidenced by a review of assessment records and transmission logs.
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Citations used to create this checklist
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