Failure to Complete MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to complete admission and annual comprehensive Minimum Data Set (MDS) assessments within the required timeframes for six out of eight residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, admission MDS assessments must be completed by the end of day 14 after admission, and annual assessments must be completed at least every 366 days. The report details that several residents had their admission or annual MDS assessments either completed late or still in progress well past the required deadlines. For example, one resident's admission MDS was completed 24 days late, another's annual MDS was still in progress at the time of survey, and others had similar delays or incomplete assessments. The deficiency was attributed to staffing issues within the MDS coordinator team. The full-time LPN responsible for MDS assessments had been on medical leave for three months, and although coordinators from sister facilities provided some assistance, the extent of their coverage was unclear. The LPN and the Nursing Home Administrator both acknowledged awareness of the late assessments and attributed the delays to difficulties in staffing the MDS coordinator position during the period in question. No additional information regarding the residents' medical histories or conditions at the time of the deficiency was provided.