Failure to Complete Timely MDS Assessment for Resident with Complex Needs
Penalty
Summary
The facility failed to complete the required Minimum Data Set (MDS) assessment for a resident within the mandated timeframe. Specifically, the quarterly MDS due on 03/18/25 was not completed for a resident with multiple complex diagnoses, including schizoaffective disorder, panic disorder, seizure disorder, PTSD, anxiety, insomnia, and depressive disorder. Previous MDS assessments documented moderate cognitive decline and no depression, with the resident routinely receiving antidepressant and anticonvulsant medications. The resident's care plan included monitoring for side effects of these medications, which have Black Box Warnings, and interventions to support mental health. Observations showed the resident was frequently sleeping and unresponsive to verbal stimuli, and staff reported that she slept a lot. The administrative nurse confirmed the expectation that MDS and Care Area Assessments (CAAs) should be completed accurately and on time. The Resident Assessment Instrument (RAI) guidelines require quarterly assessments every 92 days, which was not met in this case, resulting in a failure to ensure an accurate and timely assessment for the resident.