Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required time frame for ten residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, quarterly MDS assessments must be completed no later than 14 days after the Assessment Reference Date (ARD). However, the facility did not meet this requirement for residents R12, R14, R20, R30, R34, R35, R41, R43, R44, and R55. The completion dates for these residents' MDS assessments exceeded the 14-day requirement, with delays ranging from a few days to several weeks. During an interview on February 14, 2025, the Nursing Home Administrator and the Director of Nursing were informed of the facility's failure to complete the quarterly MDS assessments within the required timeframe for six of the 25 residents reviewed. This deficiency was identified based on a review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews, indicating a systemic issue in adhering to the mandated assessment schedule.
Plan Of Correction
By the time of the Annual Survey, the MDS Team completed the Quarterly Review for Resident 12, 14, 20, 30, 34, 35, 41, 43, 44, and 55. All residents of this facility have the potential to be affected by this practice. A house wide audit was completed to ensure quarterly assessments were done timely. The facility's MDS Team attended an in-service presented by the MDS Nurse Consultant. The Nurse Consultant or designee 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.