Failure to Complete and Transmit Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to complete and transmit quarterly Minimum Data Set (MDS) assessments for one of 47 sampled residents, as required by federal regulations. Specifically, the MDS Coordinator acknowledged that the assessments for a resident were not completed and transmitted within the mandated 14-day timeframe following the Assessment Reference Date (ARD). Review of the resident's records showed gaps in timely completion and submission of both annual and quarterly MDS assessments. The facility's policy requires that the assessment coordinator or designee ensures resident assessments are submitted to CMS' Internet Quality Improvement Evaluation System (iQIES) in accordance with federal and state guidelines. The resident involved had a complex medical history, including anoxic brain damage, acute respiratory failure with hypoxia, malnutrition, contractures of both knees, and a personal history of breast cancer. The failure to complete and transmit the required MDS assessments as scheduled could have resulted in delayed assessment of the resident's needs and monitoring of their progress over time. The MDS Coordinator confirmed during interview and record review that the assessments were late, which was not in compliance with the facility's policy and federal requirements.