Failure to Timely Submit Death in Facility MDS Assessment
Penalty
Summary
The facility failed to ensure timely submission of a Death in Facility Minimum Data Set (MDS) for one resident. The resident's last scheduled MDS assessment was submitted and validated on 11/26/24. However, the Death in Facility MDS, which was signed and locked by the responsible party on 1/7/25, was not successfully submitted or transmitted. The electronic health record indicated the assessment was marked as completed rather than accepted, showing it had not been submitted as required. A registered nurse (RN) who took over as the MDS coordinator in mid-January 2025 reported that prior to her tenure, multiple individuals had completed MDS assessments. The RN identified that the person responsible for the resident's final assessment failed to validate and submit the assessment, which would have sent it to the submission file in the Meditech system. The RN had not reviewed previous MDS submissions and was unaware of the outstanding assessment until the survey. The director of nursing (DON) stated that her expectation was for the MDS coordinator to track Assessment Reference Dates and ensure completion, validation, and submission of MDS assessments within required time frames. Facility policy required assessments to be completed and submitted according to the MDS ARD and within required time frames.