Failure to Complete Timely Comprehensive Assessment for New Admission
Penalty
Summary
The facility failed to conduct an initial comprehensive, accurate, and standardized assessment of a newly admitted resident's functional capacity within the required 14-day timeframe. Specifically, a male resident with diagnoses including dementia, Parkinson's disease, hypotension, anxiety disorder, and benign prostatic hyperplasia was admitted, but no Minimum Data Set (MDS) assessment was completed within the mandated period. Review of the electronic medical record confirmed the absence of the MDS assessment, and the MDS Coordinator acknowledged that the assessment was not completed on time, citing being behind on assessments and initially misclassifying the resident as respite due to his hospice status. Further interviews revealed that the Administrator was unaware of the overdue MDS assessments and that the MDS Coordinator, who was responsible for timely completion, reported both to regional MDS staff and directly to the Administrator at the local level. Facility policy requires comprehensive assessments to be completed within 14 days of admission, in accordance with the Resident Assessment Instrument (RAI) User Manual. The failure to complete the assessment as required resulted in the resident not having their care and treatment needs fully assessed within the appropriate timeframe.