Failure to Complete and Submit Timely MDS Assessments
Penalty
Summary
The facility failed to ensure that required Resident Assessment Instrument/Minimum Data Set (RAI/MDS) assessments were completed and transmitted to the State within the federally mandated timeframes for two residents. For one resident with chronic obstructive pulmonary disease, heart failure, mild cognitive impairment, and acute on chronic respiratory failure, the annual comprehensive MDS assessment was completed 146 days late. For another resident with type 2 diabetes mellitus, chronic kidney disease, hypertension, and anemia, the quarterly MDS assessment was completed 122 days late. These delays were confirmed through record review and interviews with the Director of Nursing (DON), who acknowledged responsibility for timely completion of MDS assessments and stated that the assessments were not completed within the required 92-day interval. Facility policy and procedure documents, reviewed during the survey, specified that the resident assessment coordinator and interdisciplinary team are responsible for ensuring timely and appropriate assessments, including quarterly and annual assessments as required by OBRA regulations. The DON confirmed that these policies were not followed, resulting in the late completion and submission of the assessments. The failure to adhere to these requirements led to inadequate monitoring of the residents' progress or decline and the lack of timely resident-specific information being submitted to CMS for payment and quality measure monitoring.