Failure to Timely Submit MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments for four out of thirteen sampled residents were transmitted to the Centers for Medicare & Medicaid Services (CMS) system within the required timeframes. Record reviews revealed that the quarterly MDS assessments for these residents, who had complex medical conditions such as diabetes mellitus, dementia, kidney failure, major depressive disorder, atrial fibrillation, lymphedema, high blood pressure, congestive heart failure, and other chronic illnesses, were not submitted on time. The MDS Assistant confirmed during interviews and record reviews that the assessments for these residents were still in progress and had not been submitted to CMS by the required deadlines. The facility's policy and procedures require that resident assessments be conducted and submitted in accordance with federal and state timeframes, with the assessment coordinator or designee responsible for timely submission. Despite this, the Director of Nursing acknowledged that late MDS assessments were discovered and had not yet been completed or submitted for the affected residents. The failure to submit these assessments as required was directly observed and confirmed by both documentation and staff interviews.