Failure to Complete MDS Assessments Within Required Time Frames
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were completed within the required time frames for five of six residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed within 14 calendar days of admission, and an annual MDS assessment must be completed no later than 14 days after the Assessment Reference Date (ARD). Review of clinical records showed that several MDS assessments were completed past these required deadlines. Specifically, one resident's annual MDS was completed two days late, another's admission MDS was completed seven days late, and additional residents had MDS assessments completed between one and eleven days after the required due dates. These findings were confirmed by the Registered Nurse Assessment Coordinator during a staff interview, who acknowledged that the facility did not complete the required MDS assessments within the mandated time frames.