Failure to Complete and Transmit Required MDS Assessments
Penalty
Summary
The facility failed to complete and transmit required Minimum Data Set (MDS) assessments for a resident who was admitted with diagnoses including bipolar disorder and epilepsy and later discharged to a psychiatric hospital. Record review showed that no MDS assessments, including entry and discharge MDS, were completed or transmitted for this resident, despite multiple assessments being due according to the facility's electronic medical record system. The MDS tracking tab indicated several assessments with Assessment Reference Dates (ARDs) that were not completed or submitted. Interviews revealed that the MDS nurse, who started after the resident's admission and discharge, had minimal training and was unaware of the outstanding MDS assessments until informed by the Administrator. The Director of Nursing (DON) and Administrator both acknowledged that the MDS coordinator was responsible for timely completion and transmission of MDS assessments, and that these had not been done as required for the resident in question. Facility policy requires all MDS assessments to be completed and transmitted in accordance with OBRA regulations, which was not followed in this instance.