Failure to Complete Admission MDS Assessment Within Required Timeframe
Penalty
Summary
Facility staff failed to complete the federally mandated Minimum Data Set (MDS) admission assessment within the required 14-day timeframe for one resident. Review of the resident's records showed that the admission MDS was not completed or submitted by the due date, as required by the RAI manual and OBRA regulations. Interviews with the DON, MDS Coordinator, and administrator confirmed that the MDS Coordinator was responsible for completing the assessment within 14 days, but the process was delayed, and the assessment was not finalized because it had not been signed by an RN. The administrator was unaware of the incomplete status of the resident's MDS assessment and did not recognize any additional time allowance for RN signature beyond the 14-day requirement.