Failure to Complete Timely MDS Entry and Discharge Assessments
Penalty
Summary
The facility failed to complete required Minimum Data Set (MDS) entry and discharge assessments within the mandated timeframes for four residents. Specifically, entry MDS assessments were not completed within 7 days for residents who were readmitted after hospital stays, and discharge MDS assessments were not completed within 14 days for residents who left the facility. Documentation showed that residents experienced hospitalizations and subsequent returns to the facility, but the necessary MDS tracking records, including entry and discharge assessments, were either incomplete or still listed as 'in progress' well after the required deadlines. Interviews and record reviews revealed that staff, including the DON, misunderstood the requirements for completing entry and discharge MDS assessments, believing they were not necessary for Medicaid residents unless the absence exceeded 10 days. The RAI Manual, however, requires these tracking records for all residents regardless of payer source or length of absence. The affected residents had complex medical histories, including conditions such as pneumonia, stroke, seizure disorder, and recent hospitalizations for acute symptoms, but the facility did not ensure timely completion and submission of the required MDS documentation.