Failure to Complete Timely Significant Change MDS Assessment After Resident Decline
Penalty
Summary
A deficiency occurred when the facility failed to complete a Significant Change in Status (SCIS) Minimum Data Set (MDS) assessment in a timely manner for a resident who experienced a notable decline in condition. The resident, who had a history of traumatic subdural hemorrhage, flaccid hemiplegia, left subdural hematoma, and falls, was admitted with moderate cognitive impairment and required varying levels of assistance with activities of daily living (ADLs) as of the last MDS assessment. By mid-March, the resident's condition had declined significantly, including increased assistance needs for transfers, eating, and hygiene, as well as changes in diet and liquid consistency due to swallowing difficulties. Despite these changes, which met the criteria for a significant change in status as outlined by both CMS and the facility's own policy, the required SCIS MDS assessment was not completed. Staff interviews confirmed awareness of the resident's decline and the need for increased care, but the responsible RN did not initiate the assessment, citing uncertainty about the requirements. The Nursing Home Administrator verified that the assessment was not completed, and the resident's Power of Attorney for Healthcare also confirmed the significant decline in the resident's functional abilities.