Failure to Complete Timely and Comprehensive MDS Assessments
Penalty
Summary
The facility failed to accurately and timely complete comprehensive assessments of residents' needs, strengths, goals, life history, and preferences, as required by federal regulations. For five residents reviewed, the Minimum Data Set (MDS) assessments were either not completed within the required timeframes or were left incomplete, with multiple sections missing critical information such as hearing, speech, vision, behavior, and bladder and bowel status. The residents affected included individuals with severe cognitive impairment, progressive neurological conditions, and other complex medical diagnoses. In several cases, the electronic medical records did not contain documentation explaining the delays or omissions in completing the MDS assessments. Interviews with facility staff confirmed that the MDS assessments were behind schedule and not finished as required. A consultant was brought in to assist with the backlog, but several assessments remained incomplete or overdue. The facility's own policy requires the interdisciplinary team to complete resident assessments in accordance with federal requirements, but this process was not followed, resulting in deficiencies in the assessment and documentation of residents' functional status and care needs.