Late Completion of Admission MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive Minimum Data Set (MDS) assessment within the required 14-day timeframe after admission for Resident #3. The resident was admitted with needs for assistance with personal care, malignant neoplasm of the prostate, uncomplicated substance abuse, long-term use of anticoagulants, and acute cystitis without hematuria. The admission MDS had an Assessment Reference Date (ARD) of January 6, 2026, and showed a BIMS score of 15, indicating intact cognition. However, the RN Assessment Coordinator’s signature verifying completion was dated January 28, 2026, which was six days past the latest allowable completion date of January 22, 2026, based on the established ARD. Review of the resident’s chart confirmed that the MDS was not completed within the required 14-day timeframe. During interviews, the MDS Coordinator stated she is responsible for tracking ARDs, completion dates, and submission dates for all required MDS assessments and that accurate and timely completion is essential for correct Medicare billing and identifying resident needs through Care Area Assessments. She reported relying primarily on a manual pencil-and-paper tracking system because the electronic record system does not consistently reflect accurate completion dates, and noted that she completes approximately 60 MDS assessments per week without a dedicated MDS assistant, with current support hours focused on care plan documentation rather than direct MDS completion. She also described system and staffing limitations, lack of coverage during her absences, delays in receiving required documentation from multiple departments, and challenges related to the resident’s multiple hospitalizations, which complicated interviews and determination of changes. The DON stated that MDS completion is monitored by a corporate MDS nurse rather than directly by her, and that staffing limitations and absences can affect workflow and contribute to backlog. Facility policy requires that the MDS be completed within 14 days after admission and within 14 days after a significant change or annually, which was not met for Resident #3.
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