Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission Minimum Data Set (MDS) assessments within the required 14-day timeframe for five residents. According to the Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following a resident's admission. However, the assessments for Residents 141, 143, 147, 152, and 165 were completed between 15 to 20 days after their respective admission dates, exceeding the mandated timeframe. The deficiency was confirmed through a review of the RAI User's Manual, clinical records, and staff interviews. The Nursing Home Administrator acknowledged that the admission MDS assessments for the mentioned residents were not completed within the required timeframes. This oversight indicates a failure in adhering to the regulatory requirements for timely assessments, which are crucial for evaluating and addressing the residents' needs and care plans.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #141 will have a timely Minimum Data Set (MDS) assessment completed. Resident #143 will have a timely MDS assessment completed. Resident #147 was discharged from the facility on 12/25/24. Resident #152 will have a timely MDS assessment completed. Resident #165 will have a timely MDS assessment completed. To identify other residents with the potential to be affected, the MDS nurse/designee will audit current residents and new admissions for the last 30 days to ensure assessments are not overdue. To prevent a future occurrence, the Nursing Home administrator/designee provided education to the MDS nurses on completion of MDS assessments in accordance with the assessment reference date. To monitor and maintain ongoing compliance, the MDS team/designee will complete an audit weekly x4 then monthly x2 to ensure MDS assessments are in accordance with the assessment reference date. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.