Failure to Complete Timely Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a required quarterly Minimum Data Set (MDS) assessment for a resident within the mandated three-month timeframe. Record review showed that the resident, a female with diagnoses including Type 2 Diabetes Mellitus, Morbid Obesity, and Asthma, had her last completed quarterly MDS assessment on 01/09/2025, with the next assessment remaining open and incomplete past the required due date. This lapse was identified during a review of the resident's electronic health record. Interviews with facility staff revealed that the MDS Coordinator had recently taken on additional responsibilities for Medicaid assessments, previously handled by a regional MDS nurse. The MDS Coordinator acknowledged awareness of the MDS timing schedule and confirmed that a missed assessment was discovered during a consultant's review. The Interim DON stated that the expectation is for MDS assessments to be completed when due and recognized that incomplete assessments could result in staff not being aware of changes in a resident's condition, as the MDS drives care planning.