Failure to Complete Timely Significant Change Assessment for Resident with Pressure Ulcer and Weight Loss
Penalty
Summary
The facility failed to complete a comprehensive significant change assessment within 14 days for a resident who experienced both a pressure ulcer and significant weight loss. The resident, who had medical diagnoses including morbid obesity, hemiplegia, depression, and dysphagia, was admitted without pressure ulcers but was at risk for them. Over time, the resident developed an open area on the coccyx and later had a stage III pressure ulcer and deep tissue injuries on both heels. The resident also experienced a weight loss of 35 pounds. Despite these significant changes, the required comprehensive assessment was not completed in a timely manner as mandated by facility policy. Interviews with the MDS Coordinator and the Director of Nursing confirmed that significant changes in condition, such as drastic weight loss or the development of stage III or IV pressure ulcers, should trigger a comprehensive assessment within 14 days. Both staff members acknowledged that these changes were discussed in daily clinical meetings, but the assessment was not completed as required. The MDS Coordinator admitted to not resetting the assessment date due to being busy, and confirmed that the 14-day window for the assessment had passed.