Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within the required timeframe for three residents. According to the CMS Resident Assessment Instrument (RAI) Manual, assessments must be completed no later than 14 calendar days after the assessment reference date (ARD) and transmitted within 7 days of completion. For three residents, the MDS assessments were not completed or submitted within these required timeframes. Specifically, one resident with severe cognitive impairment had an MDS assessment completed 24 days after the ARD and submitted 26 days after the ARD. Another resident, who was cognitively intact, had an MDS assessment completed 26 days after the ARD and submitted 28 days after the ARD. A third resident with severe cognitive impairment had an MDS assessment completed 20 days after the ARD. Interviews with the MDS Nurse and the Director of Nurses confirmed that the assessments were not completed and submitted according to the RAI manual requirements. The MDS Nurse acknowledged that quarterly MDS assessments should be submitted within 14 days of the ARD, but this was not done for the three residents in question. The Director of Nurses also stated that he would expect MDS assessments to be completed and submitted as per the RAI manual, which did not occur in these cases.