Failure to Timely Complete and Submit Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete and submit a significant change Minimum Data Set (MDS) assessment within 14 days after determining a significant change in a resident's physical or mental condition, as required by the Resident Assessment Instrument (RAI) Manual and facility policy. The resident involved had multiple diagnoses, including metabolic encephalopathy, Alzheimer's disease, depression, anxiety disorder, and type 2 diabetes mellitus. The significant change MDS, triggered by a wound greater than stage 2, was not submitted, nor was the subsequent quarterly MDS, both of which remained in progress past their due dates. Interviews with facility staff revealed that the MDS schedule is reviewed daily in morning meetings, and the electronic medical record system indicates when assessments are due. Despite these processes, the MDS Coordinator acknowledged a chronic issue with late submissions and stated that the facility was not up to date with assessments. The DON and Administrator were only recently notified of the late assessments, and the MDS RN confirmed that the care plan and kardex would not be updated without the completed MDS, leaving floor staff without updated care interventions for the resident.