Ask Proactive – We had a resident that was discharged home with family, return not anticipated. He suffered a fall after returning home, the family decided they could not care for him and readmitted him to our facility 8 hours after discharge. Since he wasn’t out after midnight, do we have to complete discharge/entry MDS assessments?

A:

At the time of discharge, the clinical team’s understanding was that this was a ‘Discharge Return Not Anticipated’ because the resident was returning home. A discharge assessment would need to be completed indicating return not anticipated, followed by an entry assessment. He would then be treated as a new resident with the MDS schedule starting over with an OBRA Admission assessment.

If the resident was previously Med A, the team would need to review the condition upon return and determine if skilled services would be appropriate and related to the original qualifying hospital stay.