Failure to Complete and Transmit MDS Assessments Timely and Accurately
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed, encoded, and transmitted within the required timeframe for one of fourteen sampled residents. Specifically, a staff member responsible for MDS assessments did not complete a re-entry MDS for a resident who was discharged to the hospital and subsequently readmitted. The staff member reported limited training, having only three days of MDS instruction, and was unaware of the process to correct or add a re-entry MDS. Review of the resident's records confirmed the absence of a required re-entry MDS following the resident's return from the hospital, and the next assessment completed was a quarterly assessment instead. Additionally, the same staff member, who was responsible for submitting the facility's MDS reports, indicated a lack of knowledge regarding the identification and correction of MDS submission errors. Facility records and quality reporting status reports revealed multiple errors, including incorrect Medicare Beneficiary Identifiers, duplicate assessments, late assessments, and resident mismatches. These issues resulted in inaccurate and missing MDS data, as identified during the annual recertification survey.