Failure to Complete and Transmit Admission MDS Assessment Timely
Penalty
Summary
The facility failed to complete and transmit an accurate and complete Minimum Data Set (MDS) assessment for a resident within the required 14-day timeframe following admission. Record review showed that the resident's admission MDS assessment was signed as completed 18 days after admission, exceeding the regulatory requirement. The delay was confirmed through interviews with facility staff, including the DON, Director of Reimbursement, and MDS Consultant, who indicated that the MDS process was being managed remotely due to staffing shortages and that the facility was in the process of hiring a new MDS nurse. The previous MDS Coordinator had recently left, and interim coverage was being provided by the Director of Reimbursement and an MDS Consultant. The deficiency was identified for one resident whose admission MDS assessment was not completed and transmitted to the CMS system within the mandated period. The facility's policy was to follow the RAI manual for MDS completion, but due to turnover and gaps in MDS staffing, the assessment was not finalized on time. Staff interviews confirmed the late completion and acknowledged the staffing challenges that contributed to the delay.