Failure to Complete Timely Admission MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for one resident within the required timeframe following admission. The resident was admitted with multiple diagnoses, including neoplasm of the meninges, nontraumatic intracerebral hemorrhage, lack of coordination, muscle weakness, foot drop of both feet, and reduced mobility. The resident's Admission MDS, dated 11 days after admission, lacked the required signature of the RN Assessment Coordinator, indicating it was not fully completed. The MDS Coordinator confirmed that the assessment was not finalized because all departments had not completed their assigned sections. During interviews and record reviews, it was established that the resident was alert, communicative, and expressed a desire to receive rehabilitation services to regain mobility and return home. The resident reported a history of multiple brain surgeries and previous use of a single point cane due to left leg weakness. The failure to complete the Admission MDS by the 14th day of admission, as required by the Resident Assessment Instrument (RAI) Manual, was acknowledged by the MDS Coordinator, who noted that this could result in areas of care not being addressed for the resident.