Failure to Timely Complete Significant Change MDS After Hospice Discharge
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment within 14 days after a resident was discharged from hospice services, as required. The resident in question had multiple diagnoses, including Alzheimer's disease, dementia, hypertension, osteoarthritis, anxiety disorder, COPD, bipolar disorder, muscle weakness, and abnormal posture. The resident was admitted to hospice services and later discharged due to medical stability, but the facility did not update the MDS or the comprehensive care plan to reflect this significant change in condition within the required timeframe. Interviews with facility staff revealed that the MDS nurse was new to the position and was still learning the process, and only recently became aware of the resident's discharge from hospice. The care plan continued to indicate the resident was receiving hospice care, and the Significant Change MDS was completed more than 14 days after the resident's discharge from hospice. The facility's policy and the RAI manual guidelines both require timely completion of the MDS following a significant change in a resident's status.