Failure to Complete and Timely Submit Comprehensive MDS Assessment
Penalty
Summary
The facility failed to complete the Comprehensive Minimum Data Set (MDS) assessments for a resident both thoroughly and within the required timeframe. Specifically, the annual MDS assessment for the resident, with an Assessment Reference Date (ARD) of 10/12/24, was missing critical sections, including Section C (Cognitive Patterns) and Section D (Mood), which were not completed as indicated by blank entries. The MDS Director confirmed that these sections, which include the Brief Interview for Mental Status (BIMS) and the Resident Mood Interview, were not done, and attributed responsibility for one section to social work. The absence of these completed sections meant that the resident's participation in required interviews and assessments was not documented as mandated. Additionally, the MDS assessment was not completed within the regulatory timeframe. The RN Assessment Coordinator verified the assessment completion on 11/27/24, which exceeded the 14-day requirement following the ARD. Most sections of the MDS, except for Section F (Activities), were completed more than two weeks after the ARD, with some sections finalized as late as 11/27/24. The MDS Director acknowledged that the assessment was not submitted in a timely manner, confirming the deficiency in both the thoroughness and timeliness of the resident's assessment process.