Failure to Transmit MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments for a resident who experienced a significant change in status and a discharge with return anticipated, within the required timeframe. The MDS assessments for this resident were completed on 5/16/25, but there was no documentation of a transmitted or accepted date for either assessment. According to the Resident Assessment Instrument 3.0 User's Manual, these assessments are required to be transmitted within 14 days of completion. Review of batch transmission reports confirmed that neither assessment was transmitted during the relevant period. Interviews with facility staff revealed a lack of clarity regarding the timing requirements for MDS transmissions. The MDS Assistant was unsure of the requirements, and the Dementia Unit Coordinator confirmed that the assessments should have been transmitted before the date of the survey. The Assistant Director of Nursing explained that the computer system requires manual designation of assessments as ready to be transmitted, which had not been done for this resident. The Director of Nursing acknowledged that the staff failed to mark the assessments as ready, resulting in the missed transmission.