Failure to Complete and Transmit MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to ensure that a comprehensive entry Minimum Data Set (MDS) assessment was encoded and transmitted within the required timeframe for one resident. Record review showed that the resident was admitted with chronic obstructive pulmonary disease and pneumonia, and later had significant changes in care, including admission to hospice services. Examination of the electronic health record revealed that several MDS assessments, including a discharge MDS, an entry MDS, a significant change MDS, and a quarterly MDS, were either not completed or not transmitted as required. The care plan had not been updated to reflect the resident's changes in care. During interview, the MDS Coordinator confirmed that the significant change MDS and other required assessments were incomplete and not submitted within the mandated timeframes, and that the facility did not have a specific policy for MDS timing, relying instead on the RAI OBRA guidelines.