Delayed MDS Assessments for Residents
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required timeframes for seven residents. According to the Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission, and an annual MDS assessment must be completed by the Assessment Reference Date (ARD). However, the facility did not adhere to these guidelines, resulting in delayed assessments for several residents. Specifically, the report highlights that residents had MDS assessments completed beyond the stipulated deadlines. For instance, one resident had an ARD of November 13, 2024, but the MDS was completed on November 28, 2024. Another resident had an admission date of January 13, 2025, with the MDS due by January 27, 2025, but it was not completed on time. These delays were identified during a review of clinical records and confirmed through staff interviews, indicating a systemic issue in meeting the required assessment timelines.
Plan Of Correction
By time of the annual survey, the MDS Team completed the Comprehensive Assessment for Resident 1, 23, 45, 49, 52, 57, and 58. All residents of this facility have the potential to be affected by this practice. A house wide audit was completed to ensure that comprehensive assessments were completed timely. The facility's MDS Team attended an in-service presented by the MDS Nurse Consultant. The Nurse Consultant will review the assessment schedule monthly to ensure timely completion. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.