Delayed MDS Submission Following Resident Death
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) for a resident within 14 days of the resident's death, as required by federal regulations. The resident was admitted with diagnoses including malignant neoplasm of the stomach and prostate and expired in the facility. Review of records showed that the MDS was not submitted until several months after the resident's death, well beyond the required 14-day timeframe. Interviews with facility staff, including the MDS Assistant and the Director of Nursing, confirmed that the MDS submission was delayed and acknowledged the requirement for timely transmission. The facility's own policy also specified that a death in the facility tracking record must be transmitted within 14 calendar days, which was not followed in this instance.
Plan Of Correction
F640: ENCODING/ TRANSMITTING RESIDENT ASSESSMENTS CORRECTIVE ACTION The MDS assessment for Resident 2 was completed on 3/7/2025 and transmitted the same day to reflect accurate patient's status. OTHER RESIDENTS AFFECTED IDENTIFICATION A comprehensive MDS audit was conducted by the MDS team on 3/21/25, no other resident noted to be affected by this deficient practice. MEASURES AND SYSTEMIC CHANGES The MDS coordinator was reeducated on the importance of timely and accurate completion and submission of MDS assessments on 3/21/2025. This education included training on the regulatory requirements and the potential impact of delayed assessments. MEASURES AND SYSTEMIC CHANGES (CONTINUED) The facility will implement regular, ongoing education to ensure that the current MDS coordinator and new staff members are trained on MDS requirements upon hire. c. The DON/Designee will be assigned to monitor MDS deadlines weekly x3 months, ensuring that assessments are scheduled, completed, and submitted in a timely manner. PERFORMANCE MONITORING This plan of correction will be integrated into our performance improvement process through a review of the plan of correction during our monthly quality assurance meeting monthly x3 or until deficient practice is resolved. During which the Admin/Designee will report any findings specific to sustaining compliance and recommendations from the QAA committee to identify outcomes and trends ensuring plan of action is achieved, sustained, and evaluated for effectiveness. MEASURES AND SYSTEMIC CHANGES (CONTINUED) The facility will implement regular, ongoing education to ensure that the current MDS coordinator and new staff members are trained on MDS requirements upon hire. c. The DON/Designee will be assigned to monitor MDS deadlines weekly x3 months, ensuring that assessments are scheduled, completed, and submitted in a timely manner. PERFORMANCE MONITORING This plan of correction will be integrated into our performance improvement process through a review of the plan of correction during our monthly quality assurance meeting monthly x3 or until deficient practice is resolved. During which the Admin/Designee will report any findings specific to sustaining compliance and recommendations from the QAA committee to identify outcomes and trends ensuring plan of action is achieved, sustained, and evaluated for effectiveness.