Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident, identified as R27, who experienced a significant change in condition. The resident, admitted on December 24, 2021, had diagnoses including dementia, Wernicke's encephalopathy, and schizophrenia. A physician order dated November 27, 2024, indicated that the resident was admitted to hospice care, which constitutes a significant change in the resident's condition. However, the facility did not complete a significant change MDS assessment to reflect the inclusion of hospice services. During interviews conducted in January 2025, both the Director of Nursing and the Nursing Home Administrator confirmed that the facility failed to complete the required significant change MDS assessment for the resident. This oversight was identified during a clinical record review and staff interviews, highlighting a deficiency in the facility's compliance with the requirement to conduct a comprehensive assessment within 14 days of determining a significant change in a resident's condition.
Plan Of Correction
1. MDS cannot be corrected. 2. Audit of residents starting hospice in the past 14 days will be completed by the RNAC or designee to ensure a significant change MDS has been completed. 3. Education will be completed with RNAC by the Regional Nurse Consultant on when to schedule a comprehensive assessment after a Significant Change in status. 4. Audits will be completed by RNAC consultant or designee weekly for 4 weeks for all residents starting hospice care for scheduling and completion of a Significant Change MDS. The QAPI committee will determine the need for further audits.