Failure to Complete and Submit Timely MDS Assessments
Penalty
Summary
The facility failed to conduct and submit timely comprehensive Minimum Data Set (MDS) assessments for three residents out of six reviewed, as required by federal regulations. Specifically, one resident was admitted and discharged within the review period, with MDS assessments completed but not reflecting an 'accepted' status. Another resident had a discharge MDS assessment completed but not submitted, and a third resident did not have a discharge assessment completed at all. These failures were identified through closed record reviews and confirmed by the facility's MDS Coordinator, who acknowledged the missing or unsubmitted assessments. The MDS Coordinator explained that, in one case, the assessment was uploaded to the electronic record keeping platform but the 'accepted' date was not entered, and in two other cases, discharge assessments were either not completed or not submitted. The findings were supported by documentation and photographic evidence. No information was provided regarding the residents' specific medical histories or conditions at the time of the deficiency.
Plan Of Correction
Specific Corrective Action On 07/18/2025 the MDS Nurse completed a Comprehensive Assessments for Residents #2, #35, and #21. Method to Assess Other Residents All residents of this facility have the potential to be affected by this practice. The facility's MOS Nurse will attend an inservice training presented by the MDS Nurse Consultant on 8/19/2025. Systematic Review Internal review of the MDS submittals will be conducted on a monthly basis by the MDS Coordinator, the Director of Nursing, and/or designee per Facility Policy (Attachment F). The Nurse Consultant will review the assessment schedule quarterly to ensure timely completion. Quality Assurance The Director of Nursing, Risk Manager, or designee will be responsible to ensure compliance of the process to the Administrator by implementing and assuring all audits (Attachment G). Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such time that consistent substantial compliance has been achieved as determined by the committee. Findings of this audit will be discussed with the Resident Council.