Failure to Complete Admission MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to complete comprehensive admission Minimum Data Set (MDS) assessments within the required timeframe for 10 out of 35 residents reviewed. According to federal regulations and the Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 13 calendar days after a resident's admission. The review of clinical records revealed that for multiple residents, the MDS assessments were completed between one and eight days past the required deadline. Specific examples include residents whose admission dates and corresponding MDS completion dates showed delays ranging from one to eight days. For instance, one resident admitted on May 5 had their MDS completed on May 19, which was one day late, while another admitted on May 12 had their MDS completed on June 12, which was eight days late. These findings were corroborated by documentation in section Z0500B of the MDS and confirmed during an interview with the LPN Assessment Coordinator, who acknowledged that the assessments were not completed within the mandated timeframes. The deficiency was identified through a combination of clinical record review, reference to the RAI User's Manual, and staff interviews. The report does not provide additional details about the residents' medical histories or conditions at the time of the deficiency, focusing solely on the failure to meet the required assessment completion deadlines as specified by federal and state regulations.
Plan Of Correction
Resident 14 no longer resides in the facility. Resident 26 no longer resides in the facility. Resident 34 was assessed with no noted concerns related to her May 26th Admission Minimum Data Set Assessment being completed on June 2, 2025, which was one day late. Resident 43 was assessed with no noted concerns related to her May 7th Admission Minimum Data Set Assessment being completed on May 19, 2025, which was six days late. Resident 44 no longer resides in the facility. Resident 139 no longer resides in the facility. Resident 140 no longer resides in the facility. Resident 141 no longer resides in the facility. Resident 142 no longer resides in the facility. Resident 143 no longer resides in the facility. Any resident admitted to the facility has the ability to be affected by this alleged deficient practice. A whole house audit of recent resident admissions was completed to ensure the Admission Minimum Data Set Assessments were completed on time. Nursing Home Administrator completed re-education with the Registered Nurse Assessment Coordinator and Licensed Practical Nurse Assessment Coordinator of the need to have Admission Minimum Data Set Assessments completed timely, no later than the resident's admission date plus thirteen calendar days as per the Long-Term Care Facility Resident Assessment Instrument User's Manual. Resident 142 no longer resides in the facility. Resident 143 no longer resides in the facility. Any resident admitted to the facility has the ability to be affected by this alleged deficient practice. A whole house audit of recent resident admissions was completed to ensure the Admission Minimum Data Set Assessments were completed on time. Nursing Home Administrator/designee will audit Admission Minimum Data Set Assessments weekly times four weeks, monthly times three months. Results of these audits will be reviewed in Quality Assurance and Performance Improvement for results, areas of improvement and/or continuation of audits times four months or until substantial compliance is noted.