Failure to Complete Timely Resident Assessments
Penalty
Summary
The facility failed to ensure timely completion of comprehensive assessments for residents as required by regulatory timeframes. Specifically, the assessments for four residents were not completed within the mandated 14 calendar days after admission or the assessment reference date. Resident #53's admission assessment was completed 21 days after admission, Resident #220's was completed 18 days after admission, and Resident #99's annual assessment was completed 20 days after the assessment reference date. These delays were contrary to the facility's policy and the Centers for Medicare and Medicaid Services' requirements. Interviews with the facility's Minimum Data Set (MDS) Coordinators revealed a lack of clarity and communication regarding the timely completion and submission of assessments. MDS Coordinator #1 acknowledged the delays but could not provide reasons for them. The Director of Nursing was unaware of the assessment timelines, and the Administrator was not informed of any issues related to the timeliness of the assessments. The MDS Coordinators indicated that the corporate staff were responsible for initiating and submitting the assessments, which contributed to the delays.
Plan Of Correction
Plan of Correction: Approved February 11, 2025 1. The MDS and assessments of the 4 affected residents will be reviewed to ensure they are complete and accurate. The residents will be reassessed by an RN and the Medical Record will be reviewed as well to ensure there are no adverse effects to the resident as a result of the late assessment. The late assessments were already completed and the associated MDS submitted so no corrective action is possible regarding the past time frame. 2. All resident assessments and MDS have the potential to be affected. The facility will audit all MDS submitted for new admission in the last quarter to identify any other late assessments. 3. The nurses working in the MDS department as well as nursing administration and unit managers will be educated on the requirement to complete all comprehensive assessments within the regulatory timeframes as noted in the Centers for Medicare and Medicaid Services specified Resident Assessment Instrument (RAI). An audit will be conducted on 3 new admissions per audit to ensure compliance with timely assessment. 4. The New Admission Assessment Audit will be conducted weekly x 4 and then monthly x 3 on three randomly selected new admissions and then three randomly selected residents on an ongoing basis quarterly. The auditor will review their MDS and related assessments to ensure they were completed within the required time frame. Results of the audits will be brought to the QAPI meeting for review. The Director of Nursing is the responsible party.