Failure to Complete Timely MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed in a timely manner for four residents out of sixteen reviewed. Specifically, one resident's MDS assessment related to death in the facility was noted as 'in process' and had not been completed or submitted as required. For three other residents, quarterly MDS assessments were not completed within the required 120-day timeframe, with the assessments only being completed after the deadline had passed. During interviews, a registered nurse acknowledged that several resident assessments were late and had been missed, and that the team was unaware of the incomplete death in facility record for one resident. The nursing home administrator was also not aware that the required MDS assessments had not been completed on time for the affected residents. These findings were based on both record review and staff interviews.