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.
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.
A resident with traumatic spinal cord dysfunction, anemia, neurogenic bladder, and lymphedema suffered a significant leg wound during care, yet the care plan was not updated to include interventions for lymphedema or skin integrity. Staff and administration confirmed the care plan did not reflect the resident's current needs.
Two residents did not have their required comprehensive assessments completed within the mandated timeframes, including a discharge MDS and an admission assessment, due to system errors and oversight, as confirmed by record review and staff interviews.
The facility did not complete comprehensive MDS assessments and Care Area Assessments within the required regulatory time frames for multiple residents. Several assessments were completed one to three days late, and in one instance, a resident did not have an MDS completed in over a year. Staff confirmed these delays during interviews.
Comprehensive MDS assessments and Care Area Assessment processes were not completed within the required time frames for multiple residents, with assessments being finalized several days late. The RNAC confirmed that these delays occurred, as identified through review of clinical records and staff interviews.
The facility did not complete comprehensive admission MDS assessments within the required 14-day timeframe for several residents, with delays ranging from one to eight days. This deficiency was confirmed through clinical record review and staff interviews, as mandated assessment deadlines were not met.
Comprehensive MDS assessments were not completed within the mandated 14-day period for four residents. Both the DON and the administrator confirmed that these assessments were completed late, in violation of regulatory requirements.
The facility did not complete federally required MDS assessments within the specified time frames for four residents with complex medical conditions, including those with tracheostomy, TBI, COPD, dementia, and respiratory failure. Required assessment and care planning documentation was signed off days to weeks late, as confirmed by the administrator.
The facility did not complete comprehensive MDS assessments within the required time frames for multiple residents, with assessments being finalized between one and eleven days late. This was confirmed by the RN Assessment Coordinator, who acknowledged the failure to meet mandated deadlines.
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