Failure to Complete Timely Discharge MDS Assessments
Penalty
Summary
The facility failed to complete and submit timely discharge Minimum Data Set (MDS) assessments for two nonsampled residents. For one resident, the discharge MDS assessment was completed more than four months after the required 14-day deadline following discharge, and for another resident, the assessment was completed 18 days after the required deadline. These delays were confirmed through closed medical record reviews and interviews with the MDS Assistant, who acknowledged that the assessments were not completed within the mandated timeframe. The failure to complete these assessments on time resulted in a delay in submitting required data to CMS regarding the residents' health and functional status at discharge. The deficiency was identified through both interview and medical record review, with specific attention to the completion dates of the discharge MDS assessments compared to the required deadlines as outlined in the Resident Assessment Instrument User's Manual.