Late Completion of Quarterly MDS Assessment Due to Staffing Shortages
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident’s quarterly Minimum Data Set (MDS) assessment was completed within the required timeframe as outlined in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. The manual specifies that quarterly MDS assessments must be completed at least every 92 days following the previous assessment, and the completion date must be no later than 14 days after the Assessment Reference Date (ARD). In this case, the resident’s quarterly MDS assessment was completed 20 days after the required deadline. The delay was attributed to staffing challenges 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 assisted during this period, the extent of their coverage was unclear. Upon returning, the LPN and the Nursing Home Administrator acknowledged the late completion of the assessment and cited difficulties in maintaining adequate MDS staffing during the absence.