Failure to Complete Timely MDS Assessments Due to Leadership Gaps
Penalty
Summary
The facility failed to complete Minimum Data Set (MDS) assessments within the required 14-day timeframe for four residents reviewed. Facility policy requires a comprehensive assessment within fourteen days of admission, with the Assessment Coordinator responsible for ensuring timely completion. Record reviews showed that for multiple residents, including those with complex medical conditions such as congestive heart failure, dementia, diabetes, respiratory failure, and chronic kidney disease, the MDS assessments were either not completed or were significantly overdue. For example, one resident's quarterly MDS was still in progress well past the Assessment Reference Date, and another had both entry and admission MDSs overdue by 12 to 18 days. In some cases, the admission MDS was not completed until well after the deadline. Interviews with staff revealed a lack of clarity and accountability regarding MDS responsibilities. The LPN newly assigned to the MDS role reported that some residents did not have MDS assessments completed and that the previous DON, who was terminated, had not completed any MDSs during her tenure. The Assistant Director of Nursing stated she was unaware of the MDS and care plan status and had not assumed DON responsibilities. The Medical Director acknowledged the importance of timely MDS completion but stated he was not involved in the process. These findings indicate that the absence of a responsible party for MDS assessments during a period of leadership transition led to the deficiency.