Failure to Complete Significant Change MDS Assessment After PEG Tube Placement
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident who experienced a major change in condition. The resident was readmitted with diagnoses of hypertension, malnutrition, and depression, and had a percutaneous endoscopic gastrostomy (PEG) tube placed during a recent hospital stay. Documentation in the clinical record, including physician orders and care plans, indicated the initiation of enteral feeding and water flushes via the PEG tube, reflecting a substantial change in the resident's nutritional status and care needs. Despite these changes, a review of the resident's MDS assessments revealed that a significant change MDS was not completed to capture the new PEG tube and related care requirements. During staff interview, the Registered Nurse Assessment Coordinator (RNAC) confirmed that the significant change MDS was not completed, stating that the team discussed the situation and decided it was unnecessary. This omission was identified during the survey and was found to be out of compliance with regulatory requirements for timely and appropriate assessment following a significant change in a resident's condition.