Failure to Complete Timely Comprehensive MDS Assessment After Admission
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive Minimum Data Set (MDS) assessment within 14 calendar days of admission for one resident who was reviewed for discharge planning. Record review showed that this resident was admitted to the facility and later discharged, but there was no documented comprehensive MDS assessment in the medical record during the resident’s stay. During an interview, the MDS coordinator confirmed that the resident had been readmitted, that staff did not complete or document an admission MDS for this resident, and that facility expectations were for an admission MDS to be completed for all residents within 14 days of admission. The coordinator further confirmed that the admission MDS for this resident should have been completed by a specific date, but it was not done. This failure to complete and document the required comprehensive MDS assessment within the regulatory timeframe constituted the identified deficiency for this resident among those reviewed for discharge planning.
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