Failure to Complete and Sign Required Resident Assessments Within Mandated Timeframes
Penalty
Summary
The facility failed to complete and sign required resident assessments, including admission, quarterly, and discharge Minimum Data Set (MDS) assessments, within the mandated time frames for three residents. Clinical record reviews showed that for one resident, the admission MDS was incomplete and unsigned past the due date, with key sections such as GG and V not finalized. Another resident's discharge MDS was also incomplete, with multiple sections still in progress and unsigned after the expected completion date. A quarterly MDS for a third resident remained in progress with numerous errors and incomplete sections beyond the required timeframe. Staff interviews confirmed that the MDS Coordinator was responsible for these assessments and acknowledged the overdue status of the assessments. The facility did not have a formal MDS policy, relying instead on a scheduling document that outlined required completion timelines for OBRA and PPS assessments. Review of the Resident Assessment Instrument (RAI) Manual confirmed the regulatory deadlines for assessment completion, which were not met in these cases. The MDS Coordinator and DON both acknowledged the delays and incomplete status of the assessments, with the DON noting the MDS Coordinator's heavy workload. No evidence was found of completed or signed assessments within the required periods for the residents reviewed.