Failure to Complete Timely Comprehensive MDS Assessments for New Admissions
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within 14 calendar days after admission for three residents, as required by regulation. For one resident, the comprehensive MDS sections were not completed until several weeks after admission, and the care plan was incomplete, only noting a behavior problem and medication use. Another resident's MDS sections were not signed as completed until well after admission, and no comprehensive care plan had been started for this individual. For the third resident, only one section of the comprehensive MDS was completed and signed, with no evidence of a full assessment. Interviews with facility staff revealed confusion and lack of clarity regarding responsibilities for timely completion of MDS assessments and care plans. The DON stated that care plans are a group effort, with the social worker responsible for opening the baseline care plan, and acknowledged that delays or inaccuracies in MDS completion could impact staff knowledge of resident care needs and preferences. A remote LVN indicated that while he compiles information for the MDS, he is not responsible for ensuring timeliness, placing that responsibility on the VPR. The VPR confirmed awareness of late MDS submissions, attributing the issue to an unfilled MDS position and reliance on remote workers to assemble assessments from onsite staff documentation. Review of facility policy confirmed the requirement to complete and transmit all MDS assessments in accordance with OBRA regulations. The failure to complete timely and accurate comprehensive assessments and care plans for newly admitted residents was directly observed in the records reviewed and acknowledged by staff, with the potential to affect the quality and appropriateness of care provided.