Failure to Complete and Sign Quarterly MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to complete and sign quarterly Minimum Data Set (MDS) assessments within the required federal timeframes for several residents. Specifically, one resident's quarterly MDS assessment was not completed within 92 days of the previous assessment, resulting in the assessment being 27 days overdue. Additionally, three other residents had quarterly MDS assessments that were not signed as complete within 14 days of the Assessment Reference Date (ARD), as required by the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. The facility's own policy also mandates adherence to these federal and state submission timeframes. Interviews with the Director of Nursing (DON) and the Administrator confirmed awareness of the overdue and incomplete MDS assessments. The Administrator attributed the delays to recent staff transitions, noting that the current MDS Coordinator had only been in the role for about two weeks. The residents affected had various medical histories, including heart failure, diabetes mellitus, dementia, cerebral infarction, hypertension, chronic kidney disease, and cerebrovascular disease. The deficiencies were identified through record review, policy review, and staff interviews.