Failure to Complete Quarterly MDS Assessments as Required
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments for five sampled residents as required by regulation. During an interview and record review with the Administrator/Minimum Data Set Coordinator (ADM/MDSC), it was found that several residents did not have their quarterly MDS assessments completed within the required timeframe. Specifically, one resident had no quarterly MDS assessment, another had no quarterly assessment completed for an extended period, and two residents had their last quarterly assessments completed several months prior to the review. The ADM/MDSC acknowledged responsibility for the completion and transmission of all residents' MDS assessments and confirmed that these assessments were late. The review referenced the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, which requires that quarterly assessments be completed at least every 92 days following the previous OBRA assessment. The failure to complete these assessments as scheduled could result in delayed assessment of residents' needs and hinder the ability to monitor residents' progress over time. The findings were based on direct record review and staff interview, with no mention of corrective actions or follow-up steps taken at the time of the report.