Failure to Complete Timely Comprehensive Admission MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive admission MDS assessment within 14 days of admission for one resident. Record review showed that this resident, a male with multiple diagnoses including a non-pressure chronic ulcer of the left heel, DM type 2, hyperlipidemia, insomnia, cellulitis of the left lower limb, peripheral vascular disease, a right below-knee amputation, and hypothyroidism, was admitted on a specified date. His admission MDS assessment, dated later in the month, showed no evidence that it was completed and no Care Area Assessments (CAAs) were triggered, despite the facility’s policy requiring a comprehensive assessment within 14 days of admission. Nursing documentation from the admission date described the resident as having a PICC line in the right upper arm, bowel and bladder incontinence, a right below-knee amputation, requiring two-person assistance with bed mobility and toileting, a mechanical lift for transfers, one-person assistance with dressing, hygiene, and bathing, supervision with eating and drinking, and the use of upper and lower dentures. The care plan initiated on the admission date included care areas and interventions for evidence-based practice, peripheral vascular disease, DM, incontinence, osteomyelitis, IV access, ADL self-care deficit, oral/dental health problems, and pressure ulcer care. A facility Resident Matrix later listed the resident as having a stage 4 pressure ulcer and being admitted on the same date, but did not reflect that he was receiving IV therapy, and there was no evidence in that document that he was receiving medication for diabetes, had an infection, or was on IV therapy. During observations and interviews, the resident was seen in bed with an IV pole, an IV access site in the right upper arm with an intact dressing, and a wound vac on the left heel with an intact dressing. He reported receiving IV medication for infection and care for his IV access and wound vac. The DON stated that the resident was on IV therapy and that the Matrix did not list IV therapy because it pulled from the MDS, which had not triggered IV therapy due to the incomplete assessment. The MDS Coordinator responsible for the admission assessment acknowledged that it had not been completed because she was behind on assessments and stated that the admission MDS should have been completed by a specific date. Facility leadership interviews confirmed that MDS Coordinators were responsible for completing comprehensive assessments, that there was no active monitoring process by the DON for timely completion, and that the facility policy required comprehensive assessments within 14 days of admission, with results used to develop, review, and revise the comprehensive plan of care.
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