Failure to Complete and Submit Timely Resident Assessments
Penalty
Summary
The facility failed to ensure that comprehensive assessments were initiated, completed, submitted, or exported for all 17 residents reviewed for resident assessments. Multiple Minimum Data Set (MDS) assessments, including quarterly, annual, admission, and significant change assessments, were found to be overdue, not started, still in progress, or completed but not exported. Specific examples include assessments overdue by as much as 557 days, assessments sitting in the electronic queue without being exported, and assessments not initiated at all. The residents affected had a range of complex medical conditions, such as traumatic brain injury, dementia, diabetes, Parkinson's disease, fractures, and other chronic illnesses. Interviews with facility staff revealed a lack of consistent communication and process for tracking and completing MDS assessments. The MDS Coordinator acknowledged chronic issues with late submissions and described reliance on the electronic medical record dashboard and morning meetings to track due assessments. However, there was no formal documentation of submission expectations, and the MDS schedule was not consistently distributed to all relevant staff. Department heads, including the Activities Director and Director of Social Work, reported not receiving regular updates or calendars, leading to delays in completing their portions of the assessments. The deficiency was further compounded by unclear lines of responsibility and insufficient oversight. The Director of Nursing and Administrator were not consistently informed about overdue assessments, and the MDS department was understaffed, with some roles temporarily filled or vacant. Staff interviews indicated that incomplete MDS assessments resulted in care plans not being updated, which could affect the communication of resident needs and interventions to direct care staff. The facility's own policy required adherence to the Resident Assessment Instrument (RAI) Manual, but this was not followed, resulting in a systemic failure to complete and submit required resident assessments in a timely manner.