Late Completion of Re-Entry MDS Assessment
Penalty
Summary
The facility failed to complete the federally mandated Minimum Data Set (MDS) tracking entry assessment within the required seven-day timeframe following a resident's re-entry. Specifically, the MDS for a resident who was re-admitted with multiple complex diagnoses, including anoxic brain damage, acute respiratory failure with hypoxia, malnutrition, contractures of both knees, and a history of breast cancer, was not completed on time. The assessment was due on 4/15/25 but was not completed until 4/18/25, as confirmed by the MDS Coordinator during an interview and record review. The facility's policy requires that resident assessments be conducted and submitted in accordance with federal and state timeframes, and the MDS Coordinator acknowledged responsibility for ensuring timely completion. The delay in completing the re-entry MDS assessment could have resulted in a delay in identifying the resident's care needs and in the delivery of appropriate treatment, as the assessment is used to inform care planning and interventions.