Failure to Complete Timely Comprehensive MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a newly admitted resident within the required 14-day timeframe, as specified by the CMS Resident Assessment Instrument (RAI) User Manual. Record review showed that the resident, a male with multiple diagnoses including cerebral atherosclerosis, major depression, diabetes mellitus, anxiety, sleep apnea, atrial fibrillation, dysphagia, arthritis, ataxia, and a history of repeated falls, was admitted to the facility and had an incomplete admission MDS assessment. Key sections of the MDS, such as identification information, preferences, functional abilities, health conditions, special treatments, participation in assessment, and care area assessment summary, were not completed, and the assessment was not signed as completed by the required date. During an interview, the MDS Coordinator acknowledged the assessment was overdue and could not provide a reason for the delay. She stated she was still learning the process and had not completed the assessment within the regulatory timeframe. The facility's policy, based on the RAI Version 3.0 Manual, requires comprehensive assessments to be completed by the end of day 14 following admission, but this was not met for the resident in question.