Failure to Timely Submit MDS Assessments Due to Staff Absence
Penalty
Summary
The facility failed to submit quarterly Minimum Data Set (MDS) assessments within the required 14-day timeframe for one resident. Specifically, the MDS assessments for a resident with an Assessment Reference Date (ARD) of 10/21/2024 and another with an ARD of 4/18/2025 were both completed and signed by the RN Assessment Coordinator well after the mandated submission period. The facility's policy requires timely completion and submission of MDS assessments in accordance with federal and state guidelines. Interviews with the MDS Nurse revealed that the delays occurred because she was absent due to a family illness and surgery during the relevant periods, and no staff member was assigned to cover her responsibilities. The Director of Nursing confirmed the expectation for timely MDS submissions. The resident involved had medical diagnoses including epilepsy and vascular dementia, and was noted to have moderate cognitive impairment based on a Brief Interview for Mental Status (BIMS) score of 7.