Failure to Complete and Update MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to complete and update the Minimum Data Set (MDS) assessments for multiple residents within the required timeframes. Specifically, seven residents did not have their quarterly or annual MDS assessments completed within 14 calendar days of the Assessment Reference Date (ARD), as mandated by federal regulations. The residents affected had a range of medical diagnoses, including intellectual disabilities, anxiety disorder, high blood pressure, diabetes, heart disease, dementia, and other chronic conditions. The MDS assessments for these residents were completed significantly later than required, with completion dates well beyond the 14-day window after the ARD. Interviews with facility staff revealed that the MDS nurse was responsible for completing and updating the MDS assessments, but there was a lack of clarity and oversight regarding the timely completion of these assessments. The Director of Nursing (DON) acknowledged her ultimate responsibility for ensuring assessments were completed but cited her recent start in the position and the need to catch up as contributing factors. The Administrator attributed the delays to a transition period during a change of ownership, which involved transferring residents to new identification numbers and the MDS Coordinator covering multiple buildings. The MDS Coordinator also indicated that corporate instructions to delay transmission of MDS assessments until the new provider numbers were assigned contributed to the late completion. Facility policy required that MDS assessments be conducted and submitted in accordance with federal and state timeframes, specifically referencing the Resident Assessment Instrument (RAI) Manual. The manual stipulates that quarterly assessments must be completed at least every 92 days, with the MDS completion date no later than 14 days after the ARD. Despite these requirements, the facility did not adhere to the mandated timelines for the affected residents, resulting in a deficiency related to timely resident assessment updates.