Failure to Complete Timely Comprehensive MDS Assessments After Admission
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive MDS assessments within 14 calendar days of admission for three residents. For one male resident in his eighties with multiple complex diagnoses including congestive heart failure, diabetes, chronic kidney disease, anemia, hyperlipidemia, tracheostomy care, and generalized muscle weakness, record review showed a 20‑day entry MDS assessment dated on his admission date that was not completed. This failure occurred despite his extensive medical needs documented in the clinical record. A female resident with acute and chronic respiratory failure with hypoxia, chronic pain, a left heel pressure ulcer, skin infection, hypertension, protein‑calorie malnutrition, heart disease, type 2 diabetes with neuropathy, insomnia, depression, prior cerebral infarction with dysphagia, cerebrovascular disease, dementia, psychotic disturbance, mood disturbance, and anxiety was also affected. Her clinical record showed a 5‑day entry MDS dated on the day of admission with only section A completed. Her admission MDS, dated six days after admission, remained incomplete more than two weeks later, well beyond the 14‑day requirement. Another female resident with a history of ankylosing spondylitis of the lumbosacral region, displaced intertrochanteric fracture of the right femur, prior falls, senile degeneration of the brain, osteoarthritis, right artificial knee joint, wedge compression fracture of the second lumbar vertebra, major depressive disorder, dementia, psychotic disturbance, mood disturbance, and anxiety also lacked a timely comprehensive assessment. Her record showed the last completed quarterly MDS several months earlier and an admission MDS dated late in the year that remained in progress and incomplete. Interviews with the on‑site MDS coordinator and the regional MDS coordinator confirmed that the facility was behind on required MDS assessments, that the on‑site coordinator was new and still in training, that there had been a CHOW with discharge of all residents, and that one regional staff member was handling all MDSs. The facility’s written policy on conducting accurate resident assessments did not address required MDS timing.
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