Failure to Complete Timely Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required timeframe for three residents. Clinical record reviews showed that for one resident, there was a 142-day gap between the admission MDS assessment and the first quarterly assessment. For another resident, there was a 133-day interval between two quarterly assessments, and for a third resident, the gap between quarterly assessments was 95 days. According to the Resident Assessment Instrument (RAI) User's Manual, assessments must be completed no later than 92 days after the previous assessment. Interviews with the new MDS Coordinator and the Administrator revealed that the facility had experienced staffing changes, with the corporate support team intermittently handling MDS assessments while a new Coordinator was being hired. The MDS Coordinator described the process for completing assessments and acknowledged that quarterly assessments should be completed within 92 days. The Administrator confirmed that the previous Coordinator was responsible for the missed assessments, and the new Coordinator had been working to correct identified errors. The facility did not indicate on the Self Identification form that MDS corrections were an ongoing issue.