Failure to Complete Timely Significant Change Assessment After Major Injury
Penalty
Summary
The facility failed to complete a comprehensive assessment within 14 days following a significant change in condition for one resident who experienced a fall resulting in a major injury. Specifically, the resident, an elderly female with diagnoses including dementia, history of falls, macular degeneration, lack of coordination, and muscle wasting, suffered a fall in her room that resulted in an acute right humeral neck fracture. Documentation showed that after the fall, the resident complained of right arm pain, was medicated for pain, and had an x-ray confirming the fracture. Despite this significant change in her physical condition, a Significant Change Minimum Data Set (MDS) assessment was not completed within the required timeframe. Further review of the resident's records indicated that the quarterly MDS assessment did not accurately document the fall with major injury, and the significant change MDS assessment was omitted entirely. Interviews with the DON and MDS nurse confirmed that a fall with a fracture is considered a significant change and should have triggered a timely assessment. The facility's policy also requires completion of a significant change assessment within 14 days of such an event, but this was not followed in this case.