Failure to Complete Timely Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Resident Assessment Instrument/Minimum Data Set (RAI/MDS) assessments were completed within the required federal submission timeframes for two residents. For one resident with a history of hypertension, type 2 diabetes mellitus, and cerebrovascular accident, the quarterly MDS assessment was completed 52 days late. For another resident diagnosed with dementia, the quarterly MDS assessment was not completed and was 92 days overdue. These lapses were identified through interviews and record reviews with the Director of Nursing (DON), who acknowledged responsibility for completing the MDS assessments and confirmed the assessments were not completed within the required 92-day interval as outlined in the facility's policy and procedure. The facility's policy, which requires quarterly reviews to be conducted within 92 days of the previous assessment, was not followed in these cases. The DON confirmed during interviews that the policy was not adhered to and recognized the importance of timely assessments for accurate reimbursement and care planning. The findings were based on direct review of medical records and interviews with the DON, who admitted the assessments were late or not completed as required.