Failure to Complete Quarterly MDS Assessments Within Regulatory Time Frames
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required regulatory time frames for seven residents. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manual, quarterly assessments must be completed at least every 92 days following the previous OBRA assessment, with the MDS completion date no later than 14 days after the Assessment Reference Date (ARD). Medical record reviews revealed that for seven residents with various diagnoses including heart failure, dementia, chronic kidney disease, diabetes, hypertension, anxiety disorder, polyneuropathy, adult failure to thrive, and depression, the quarterly MDS assessments were either completed late or not dated as required. Specific examples included assessments that were completed weeks after the required due dates or left undated. During an interview, the MDS Coordinators confirmed responsibility for signing and verifying the completion of MDS assessments and acknowledged that the assessments for the identified residents were completed late. The deficiency was identified through a review of medical records and staff interviews, which confirmed that the facility did not adhere to the mandated timelines for completing quarterly MDS assessments for these residents.