Failure to Timely Transmit MDS Assessments Due to Staffing Shortages
Penalty
Summary
The facility failed to encode and transmit Minimum Data Set (MDS) assessments to the State and CMS within the required timeframe for three residents. For one resident with hemiplegia and lupus anticoagulant syndrome, the quarterly MDS assessment was completed but not transmitted, remaining in 'export ready' status. Another resident with type 2 diabetes mellitus, diabetic neuropathy, and sequelae of cerebral infarction also had a completed quarterly MDS assessment that was not transmitted. A third resident, admitted with a femur fracture, aftercare following joint replacement, and hypertension, had an entry MDS assessment completed but not transmitted within 14 days of completion, as required. Interviews with facility staff confirmed that the MDS assessments were completed but not transmitted due to an oversight and staffing shortages, specifically a vacant MDS nurse position. The DON acknowledged that the responsibility for transmitting MDS assessments lay with the MDS nurse and that the delay was related to having only one MDS nurse on staff at the time. Facility policy requires timely electronic transmission of accurate and complete MDS data to the CMS system.