Failure to Conduct Significant Change MDS Assessment
Penalty
Summary
The facility failed to conduct a significant change Minimum Data Set (MDS) assessment for a resident who experienced a major decline in health status. The resident, who was admitted with diagnoses including diabetes and depression, was initially independent with eating and required partial to moderate assistance for other activities. However, after being hospitalized for stroke-like symptoms and readmitted with a new diagnosis of acute cerebrovascular accident (CVA) with right-side weakness, the resident's condition significantly declined. This decline included the need for a full-body mechanical lift for transfers and assistance with eating, as observed during a lunch meal. Despite these changes, there was no documented evidence that a significant change MDS assessment was completed as required by the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual. The manual mandates a comprehensive assessment within 14 days of a significant change in a resident's condition, which impacts more than one area of health status and requires an interdisciplinary review. The Nursing Home Administrator confirmed that the required assessment was not conducted, resulting in a deficiency in nursing services as per 28 Pa. Code 211.12(c)(d)(3)(5).
Plan Of Correction
1. Significant Change Assessment Schedule for Resident 12 with ARD date of 12/24/2024. 2. Education provided to RNAC and inter-disciplinary team for guidance and definition of Significant Change Assessment. 3. Audit performed on facility census for residents with potential need of Significant Change Assessment. 4. Will audit for compliance of timely identification and completion of Significant Change Assessments weekly x 4, monthly x 2 by RNAC/designee. Finding will be reported to QAPI.