Quarterly MDS Assessment Not Completed Timely
Penalty
Summary
The facility failed to complete the quarterly Minimum Data Set (MDS) assessments within the required time frame for one resident. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the assessment reference date (ARD) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type. However, for Resident 81, the quarterly MDS assessment had an ARD of December 13, 2024, which was 116 days after the previous annual MDS assessment with an ARD of August 19, 2024. This discrepancy was confirmed during an interview with the Director of Nursing on January 17, 2025.
Plan Of Correction
1. Resident 81 suffered no ill effects. 2. Baseline audit completed to ensure all other Minimum Data Sets were completed timely by the registered nurse assessment coordinator/designee. 3. Review of the Resident Assessment Instrument manual was completed with Registered Nurse Assessment Coordinator to ensure understanding of the completion dates. 4. Audits will be completed by RNAC weekly x 2 weeks and monthly x 2 months checking for timeliness of assessments. 5. Date of compliance 3/5/2025.