Failure to Complete and Sign Quarterly MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete and sign quarterly Minimum Data Set (MDS) assessments for 10 out of 11 sampled residents, as required by federal regulations and the facility's own policy. The MDS assessments, which are mandated to be completed at least every 92 days and signed within 14 days after the Assessment Reference Date (ARD), were found to be unsigned and incomplete for multiple residents. This was confirmed through record review, document review, and interviews with facility staff. The residents affected had a range of significant medical conditions, including chronic obstructive pulmonary disease, atherosclerotic heart disease, heart failure, acute respiratory failure, type 2 diabetes mellitus with foot ulcer, essential hypertension, age-related osteoporosis, chronic kidney disease, hypertensive chronic kidney disease, anemia, and hypothyroidism. Admission records for each resident detailed their medical histories, and the corresponding quarterly MDS assessments with specific ARDs were found to be incomplete, lacking required signatures and dates to indicate completion. During interviews, both MDS Coordinators acknowledged that several MDS assessments had not been submitted and were considered late, confirming that the facility's expectation was for all assessments to be completed and submitted on time. The DON and Executive Director also stated their expectations that MDS assessments be completed and transmitted within the required timeframes, but acknowledged that this had not occurred for the residents in question.