Untimely Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) admission assessment within the required timeframe for one resident. Specifically, a resident admitted with a diagnosis of encephalopathy had an MDS admission assessment completed 15 days after the entry date, exceeding the regulatory requirement that the assessment be completed no later than 13 days after admission. The resident's admission date and the corresponding MDS documentation were reviewed, confirming the late completion. Interviews with facility staff revealed a lack of clear policy regarding the timing of MDS assessments. The MDS Coordinator stated she relied on the Resident Assessment Instrument (RAI) manual for guidance but acknowledged the assessment was not completed within the required period. The Assistant Director of Health Services was unfamiliar with the completion date requirements, and the Executive Director indicated that staff should refer to the RAI manual for timing but did not provide further direction.