Failure to Complete Significant Change Assessment for Resident
Penalty
Summary
The facility failed to complete a significant change resident assessment for a resident who experienced notable changes in their condition. The resident, diagnosed with a coagulation defect and chronic kidney disease stage 5, initially had a mood score indicating mild depression and required minimal assistance with certain tasks. However, a subsequent quarterly assessment revealed that the resident's mood score improved to indicate no depression, but their physical dependency increased significantly, requiring staff assistance for multiple tasks including toileting hygiene and mobility. Despite these changes, the facility did not conduct a significant change assessment to address the resident's altered condition. The MDS coordinator acknowledged that a significant change assessment should be completed when there are two or more areas of decline or improvement. However, they indicated that the assessment was not conducted because the resident was undergoing skilled therapy, and there was a possibility of rehabilitation. This oversight resulted in a failure to adequately assess and address the resident's changing needs.