Failure to Complete Significant Change Assessments
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for four residents, despite significant changes in their conditions. This assessment is federally mandated and should be completed within 14 days after a significant change in a resident's physical or mental condition that impacts more than one area of their health status. The report highlights that the facility did not perform these assessments for four residents out of a sample of 22, despite observable declines in their activities of daily living (ADL) and other health indicators. Resident #18 experienced a decline in ADL functions, requiring increased assistance for oral hygiene, dressing, and transfers, and became occasionally incontinent of bowel. Despite these changes, no SCSA was completed. Similarly, Resident #8 showed a decline in independence, requiring more assistance in various ADL areas, experienced significant weight loss, and developed a new swallowing disorder, yet no SCSA was documented. Resident #13 also had changes in hearing, range of motion, and required more assistance in ADL areas, but again, no SCSA was completed. Resident #28 had changes in mobility, weight, and required more assistance in ADL areas, with new pain management interventions, but the facility did not complete an SCSA. Interviews with the MDS coordinator and the Director of Nursing revealed a lack of understanding and adherence to the RAI manual guidelines, contributing to the failure to complete the necessary assessments. The MDS coordinator admitted to not using the RAI manual properly, and the Director of Nursing expected the SCSA to be initiated within a few days of a change, but this was not done as required.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a history of acute respiratory failure, mechanical ventilation, and tracheostomy was decannulated following a physician's order, but the facility did not complete a comprehensive MDS assessment within 14 days of this significant change in condition, as confirmed by staff interview and medical record review.
Three residents with multiple chronic conditions began hospice care but did not have the required Significant Change MDS assessments completed within 14 days of hospice admission, as confirmed by the MDS nurse.
A resident experienced a major decline in cognitive and functional status after a stroke, becoming nonverbal, unable to make needs known, and fully dependent on staff for all ADLs, with all nutrition provided via tube feeding. Despite these significant changes, the facility did not complete a required significant change MDS assessment, as confirmed by staff interviews and medical record review.
A resident with multiple chronic conditions, including severe cognitive impairment and total dependence for ADLs, was admitted to hospice care. The facility did not complete the required significant change MDS assessment within the mandated 14-day period, as confirmed by the MDS Coordinator and facility records.
A facility failed to complete a Significant Change MDS assessment for a resident after starting hospice services. The resident, with multiple diagnoses including cognitive impairment, was admitted to hospice care, but the required assessment was not conducted within 14 days. The DON confirmed this oversight.
The facility failed to complete significant change assessments within the required 14-day period for three residents receiving hospice services. A resident with dementia and breast cancer, another with severe cognitive impairment, and a third with heart disease were all affected by this deficiency. The assessments were completed beyond the mandated timeframe, as confirmed by an RN, violating the facility's policy.
Failure to Complete Comprehensive Assessment After Significant Change
Penalty
Summary
The facility failed to conduct a comprehensive assessment within 14 days following a significant change in condition for one resident. The resident, who had diagnoses including acute respiratory failure with hypoxia, mechanical ventilation dependence, tracheostomy, and cerebral infarction, was admitted on 08/23/24. The quarterly Minimum Data Set (MDS) assessment indicated the resident had intact cognition and was dependent on staff for activities of daily living. On 07/09/25, the resident was decannulated following a physician's order, as documented by the respiratory therapist. However, a review of the medical record showed that a comprehensive MDS assessment was not completed after this significant change in the resident's status. This was confirmed by the Regional MDS Nurse during an interview.
Failure to Complete Timely Significant Change MDS Assessments After Hospice Admission
Penalty
Summary
The facility failed to complete Significant Change in Minimum Data Set (MDS) status assessments within 14 days following the initiation of hospice services for three residents. Specifically, medical record reviews showed that each of the three residents, who had complex medical histories including conditions such as COPD, Alzheimer's disease, chronic respiratory failure, major depressive disorder, dementia, diabetes, and neurocognitive disorder, began hospice care but did not have the required Significant Change assessments completed within the mandated timeframe. This deficiency was confirmed during an interview with the MDS nurse, who acknowledged that the assessments were not performed as required for these residents.
Failure to Complete Significant Change MDS Assessment After Major Resident Decline
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) as required for a resident who experienced a major decline in condition. The resident, admitted with multiple diagnoses including cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease, was discharged to the hospital and later readmitted following a stroke. Prior to the stroke, the resident was cognitively intact, able to communicate, and required only set-up assistance for eating, consuming a regular diet by mouth. After the stroke, the resident became nonverbal, unable to make needs known, developed severe cognitive impairment, and became fully dependent on staff for all activities of daily living, receiving all nutrition via gastrostomy tube feedings. Despite these significant changes in the resident's cognitive and functional status, the facility did not complete a significant change MDS assessment within the required timeframe. Staff interviews confirmed the resident's marked decline in cognition, communication, and nutritional intake following the stroke. The facility's MDS coordinator stated she did not believe the criteria for a significant change assessment were met, despite clear evidence of major declines in multiple areas of the resident's health status. This failure was identified through medical record review, staff interviews, and review of facility policy and the RAI manual.
Failure to Complete Timely Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within the required 14-day timeframe for a resident who was admitted to hospice care. The resident, who had a history of multiple sclerosis, cerebral infarction, and vascular dementia, was noted to have severely impaired cognition and required total assistance with activities of daily living (ADLs). Record review showed that the significant change MDS assessment was not completed in a timely manner following the hospice admission order, as confirmed by the MDS Coordinator. Facility policy required comprehensive assessments to be conducted according to the timeframes established in the Resident Assessment Instrument (RAI) manual.
Failure to Complete Significant Change MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for Resident #42 after the initiation of hospice services. Resident #42, who had a range of diagnoses including lumbar degeneration, chronic obstructive pulmonary disease, alcoholic cirrhosis of the liver, anxiety, chronic viral hepatitis C, seizures, and psychosis, was admitted to hospice care as per a physician's order. Despite this significant change in condition, there was no evidence of a Significant Change MDS assessment being completed within the required 14-day period following the start of hospice services. The annual MDS indicated cognitive impairment and did not reflect the resident's terminal status or hospice care, as required by the Long Term Care Facility Resident Assessment Instrument 3.0 User Manual. The Director of Nursing confirmed the oversight during an interview, acknowledging that the assessment was not conducted during the resident's hospice care period.
Failure to Timely Complete Significant Change Assessments for Hospice Residents
Penalty
Summary
The facility failed to ensure that significant change assessments were completed in a timely manner for three residents receiving hospice services. Resident #43, who had multiple diagnoses including dementia and breast cancer, began receiving hospice services on February 6, 2024. However, the significant change Minimum Data Set (MDS) assessment was not completed until February 22, 2024, which was beyond the required 14-day period. This delay was confirmed by Registered Nurse (RN) #139, who acknowledged that the assessment should have been completed by February 19, 2024. Similarly, Resident #45, who had severe cognitive impairment and was picked up by hospice on January 2, 2025, had their significant change MDS assessment completed on January 22, 2025, instead of the required date of January 15, 2025. Resident #51, with a history of heart disease and other conditions, was also affected by this deficiency. The resident was picked up by hospice on February 6, 2025, but the significant change MDS assessment was not completed until February 22, 2025, missing the deadline of February 19, 2025. These findings were corroborated by RN #139 and were in violation of the facility's policy, which mandates that a comprehensive MDS assessment be completed within 14 days of a significant change.
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