Failure to Complete Timely MDS Assessments After Significant Change in Condition
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) comprehensive assessments within the federally required time frames for two residents who experienced significant changes in condition. Both residents had histories of dementia and schizophrenia, and each exhibited new or worsening behavioral symptoms that led to acute psychiatric hospitalizations and subsequent readmissions to the facility. Documentation, including SBAR forms and progress notes, indicated that these behavioral changes were significant departures from each resident's baseline condition. Despite this, the MDS assessments did not reflect a significant change of condition, and comprehensive assessments were not completed within 14 days of the residents' readmissions as required. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the changes in the residents' mental and behavioral status constituted significant changes in condition, necessitating timely MDS comprehensive assessments. The facility's own policy also required completion of such assessments within 14 days after determination of a significant change. The failure to complete and report these assessments in a timely manner resulted in inaccurate and delayed reporting of the residents' health status to CMS.