Failure to Complete Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for two of twelve residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, quarterly MDS assessments must be completed at least every 92 days following the previous OBRA assessment, with the completion date no later than 14 days after the Assessment Reference Date (ARD). For one resident, the quarterly MDS assessment was completed 23 days after the required due date. For another resident, the quarterly MDS assessment was still in progress and not completed by the specified deadline. The MDS Coordinator reported being the only full-time staff member responsible for MDS assessments and stated an inability to keep up with all required assessments due to lack of assistance. The Coordinator indicated that priority was being given to Medicare MDS assessments, resulting in quarterly assessments being delayed. During the Coordinator's absence, a pool nurse was covering the role, and the facility was in the process of training another RN for the position. The issue of late and incomplete MDS assessments was acknowledged by the MDS Coordinator and discussed with the Nursing Home Administrator and Director of Nursing.