Failure to Submit Timely Admission MDS Assessment
Penalty
Summary
Facility staff failed to submit a required Minimum Data Set (MDS) admission assessment within the federally mandated timeframe for one resident. Clinical record review showed that the resident was admitted on a specific date, but the admission MDS assessment, while marked as in progress, did not have a documented completion or submission date within the required 14 days. This omission was confirmed through review of the resident's facesheet and MDS records. During an interview, the MDS coordinator, an LPN, acknowledged that the admission MDS was completed and submitted before the fourteenth day, but also stated that some MDS assessments had fallen behind due to staffing issues. The deficiency was brought to the attention of the administrator and acting DON, and no further information was provided prior to the survey exit.