Late Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences within 14 calendar days after admission, as required. Specifically, the admission Minimum Data Set (MDS) assessment for a female resident with hemiplegia, hemiparesis following a stroke, and dementia was not completed on time. The resident was admitted on 03/04/2025, but the MDS assessment, which had an Assessment Reference Date (ARD) of 03/11/2025, was not signed as completed until 03/25/2025, making it 8 days late. Interviews with facility staff revealed that the MDS Coordinator, who was not an RN and worked at two different buildings, relied on the DON to sign off on MDS assessments. The MDS Coordinator attempted to notify the DON via email about assessments needing signatures, but the DON was not always able to check or sign them daily due to other responsibilities and was unaware of the required timeframes. The Administrator expected timely completion but was not aware of the clinical implications. Facility policy required a registered nurse to coordinate and sign each assessment within the specified timeframes, which was not followed in this instance.