Failure to Complete MDS Assessments Within Required Time Frames
Penalty
Summary
The facility failed to complete Minimum Data Set (MDS) assessments within the federally required time frames for four out of sixteen residents reviewed. According to the Resident Assessment Instrument (RAI) User's Manual, admission MDS assessments, quarterly MDS assessments, and discharge return anticipated MDS assessments must be completed within specific deadlines following admission, assessment reference dates, or discharge. For the residents identified, the MDS completion dates, Care Area Completion dates, and Care Plan Decision dates were all signed off several days to weeks after their required due dates. The residents affected had significant medical conditions, including tracheostomy, traumatic brain injury, seizures, COPD, lung cancer, dementia, anxiety, respiratory failure, and high blood pressure. The delays in completing the required MDS assessments were confirmed by the Nursing Home Administrator during a staff interview. The deficiency was cited under 28 Pa. Code 201.14(a) for failure to ensure timely completion of mandated resident assessments.