Failure to Complete and Submit Timely MDS Assessments
Penalty
Summary
The facility failed to complete and submit required Minimum Data Set (MDS) assessments for three residents within the mandated timeframes. For one resident with Type 2 Diabetes Mellitus and muscle weakness, both a quarterly and an annual MDS assessment had been initiated but not completed. Another resident with hemiplegia and speech deficits following a cerebral infarction had two quarterly MDS assessments initiated but left incomplete. A third resident, diagnosed with a femur fracture and Type 2 Diabetes Mellitus, also had a quarterly MDS assessment that was started but not finished. These incomplete assessments were identified through record reviews, which showed that the MDS assessments had been initiated but not finalized for each resident. During interviews, the MDS coordinator confirmed that the assessments had not been completed due to oversight and acknowledged responsibility for ensuring timely completion and submission to CMS. The Director of Nursing stated that her expectation was for MDS assessments to be initiated, completed, and exported to CMS promptly. Facility policy requires that accurate and complete MDS data be electronically transmitted to the CMS system, but this process was not followed for the residents in question.