Failure to Complete Timely MDS Assessment After Significant Change
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident, identified as R97, within the required 14-day period following a significant change in the resident's condition. The resident was admitted to the facility with diagnoses including dementia, repeated falls, and anxiety. On June 14, 2024, the resident was admitted to hospice care, which constitutes a significant change in condition requiring a comprehensive assessment. However, the facility did not complete the necessary MDS assessment to reflect this change. The deficiency was confirmed during an interview with the Licensed Practical Nurse Assessment Coordinator, who acknowledged that the facility did not conduct the MDS significant change assessment within the mandated timeframe. The facility's policy requires that such assessments be completed within 14 days of determining a significant change in a resident's condition, which was not adhered to in this case. This oversight indicates a lapse in the facility's adherence to regulatory requirements for timely assessments following significant changes in a resident's health status.
Plan Of Correction
The facility will complete a significant change Minimum Data Set (MDS) assessment for residents with a change in condition. Resident R97 MDS will be updated to reflect the significant change in Hospice services. The Facility will complete a house audit on residents receiving hospice services to validate the MDS was completed and indicates a significant change related to Hospice. The Regional Clinical Consultant or designee will re-educate the Licensed Practical Nurse Assessment Coordinator (LPNAC) on federal regulation 0623, detailing completing a significant change MDS for Hospice residents. The Director of Nursing or designee will complete an audit weekly for four weeks then monthly for three months to validate residents receiving hospice services has a MDS to reflect the significant change. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.