Failure to Complete Timely Admission MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission MDS assessments within the required 14-day timeframe for two residents. For one resident, the admission MDS assessment was signed as completed 16 days after admission, and for another, the assessment was completed 15 days after admission. Record reviews confirmed the late completion dates, and interviews with the DON and MDS Coordinator revealed that the delays were due to the absence of an RN to sign off on the MDS and an unplanned absence of the sole MDS Coordinator, with no designated backup available for unscheduled absences. Both residents had multiple medical diagnoses, including cerebral palsy, hypertension, diabetes, hypothyroidism, and a history of falls. The facility's policy and the CMS LTC RAI 3.0 User's Manual require that admission MDS assessments be completed and signed within 14 days of admission. The MDS Coordinator acknowledged that the late completion of assessments was due to staffing issues and confirmed that there was no process in place for coverage during unplanned absences, except for pre-scheduled time off.