The facility failed to complete required MDS assessments within the required timeframe for six residents. Review of records showed late admission and annual MDS completions, and the Regional Director of Operations confirmed the deficiency during interview.
Failure to complete discharge MDS assessments for two residents. One resident was admitted with chronic respiratory failure and later transferred to an acute care facility, and another resident was admitted and discharged, but neither record showed a discharge MDS. An LPN confirmed that no discharge MDS was completed for either resident after discharge.
Delayed completion of admission MDS assessments. The facility failed to ensure that comprehensive MDS assessments were completed within the required timeframe for three residents. An RNAC stated the prior position had been vacant for several months, and she confirmed the assessments were not completed on time for the affected residents.
The facility failed to complete required MDS assessments within the required time frame for four residents. An annual assessment and an admission assessment were completed late, and an RN assessment coordinator confirmed the missed time frames during interview.
A resident’s MDS record showed an admission MDS was transmitted, followed later by a quarterly assessment, but no initial comprehensive assessment was transmitted in between. The NHA confirmed that no MDS assessment was transmitted during that period.
Required admission and annual MDS assessments were not completed on time for four residents. Two residents had admission MDSs completed late, and two residents had annual MDSs completed after the due date. The DON confirmed the assessments were not completed within the required time frames.
The facility failed to complete comprehensive MDS assessments and the CAA process within required time frames for two residents. One resident had a comprehensive MDS with no prior MDS in the past year, and another resident had the same issue. The RNAC confirmed the assessments were not completed on time.
A facility failed to complete a comprehensive admission assessment for a resident with orthopedic conditions, malnutrition, DM, and respiratory failure. The resident was documented as having severely impaired vision, but legal blindness was not included in the diagnosis list on the MDS or in the clinical record primary diagnosis. The resident reported concerns about blindness, said there were no interventions for the vision loss, and stated meds were left on the overbed tray even though the resident could not see them.
A resident with diagnoses including breast cancer, CVA, and non-Hodgkin's lymphoma had a physician order for hospice consultation and treatment, and hospice services began when the hospice contract was signed by the POA. However, the RNAC coded hospice care as No on the significant change MDS, resulting in an inaccurate assessment.
Inaccurate PASRR screenings were completed for two residents. One resident had severe cognitive impairment and documented diagnoses of dementia, anxiety, depression, and bipolar disorder, yet the PASRR stated there was no mental health condition that may lead to a chronic disability. Another resident had schizophrenia and a history of psychiatric treatment and outpatient mental health services, but the PASRR contained contradictory information about those services and treatment history.
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