Failure to Complete Significant Change MDS Assessments for Residents
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for two residents, which is required when there is a significant change in a resident's condition. According to the Resident Assessment Instrument 3.0 User's Manual, a comprehensive assessment must be conducted within 14 days after determining a significant change in a resident's physical or mental condition. Resident R3, who was admitted to the facility with diagnoses of high blood pressure, depression, and dementia, was placed under hospice care as indicated by a physician order dated 11/11/24. However, a significant change MDS assessment was not completed to reflect the inclusion of hospice services. Similarly, Resident R8, who was admitted with high blood pressure, dementia, and Parkinson's disease, was also placed under hospice care as per a physician order dated 2/20/24. The facility again failed to complete a significant change MDS assessment to include hospice services for this resident. These deficiencies were confirmed during interviews with the Licensed Practical Nurse Assessment Coordinator and the Director of Nursing, who acknowledged the oversight in completing the necessary assessments for these residents.
Plan Of Correction
The Director of Nursing/designee will complete an audit of any resident admitted to hospice since Jan 1, 2025, to ensure that their MDS significant change includes documentation of hospice services. There were no negative outcomes from resident R3 or R8 not having a significant Change MDS prior to being admitted to hospice. The Director of Nursing/designee will educate the appropriate nursing staff on the appropriate documentation needed before a resident admits to hospice services. The LNAC/designee will conduct weekly audits for four weeks after any significant change MDS is completed to ensure the required documentation is present. The audit results will be submitted to the QAPI committee for review for any trends that may require further improvement plans.