Late Completion of Comprehensive MDS Assessments: The facility failed to complete required comprehensive MDS assessments and related CAA processes within the required time frames for multiple residents. Review of records showed several assessments were completed one to six days late, and the NHA confirmed the late completions during interview.
A resident's comprehensive admission MDS assessment was not completed within the required timeframe. The RAI User's Manual required the assessment within 14 days of admission, but the RN Assessment Coordinator confirmed the assessment was completed 28 days after admission.
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.
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