Failure to Complete and Submit Required MDS and Death Tracking Records
Penalty
Summary
The facility failed to ensure timely completion and transmission of Minimum Data Set (MDS) Assessments and Death in Facility Tracking Records for multiple residents. For one resident admitted with sepsis and later discharged to the community, a Discharge MDS Assessment was not completed at the time of discharge. The MDS Nurse confirmed during an interview that this assessment should have been completed but was not. Additionally, two other residents who expired in the facility did not have Death in Facility Tracking Records completed as required. Review of their records showed that, despite documentation of their deaths in nursing progress notes and pronouncement forms, the necessary MDS tracking records were not completed or submitted. The MDS Nurse acknowledged in interviews that these records should have been completed for both residents but were not, despite referencing the RAI Manual for guidance on accuracy and timeliness.