Failure to Complete Significant Change Assessment After Major Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced a major decline in two or more MDS care areas, specifically unplanned significant weight loss and the development of a new wound. The MDS Coordinator acknowledged during interview and record review that a significant change MDS should have been completed at the same time as the quarterly MDS, as the resident had a notable decline in health status, including a 23% weight loss over six months and the appearance of new pressure ulcers. The quarterly MDS assessments documented an increase in the number of Stage 4 pressure ulcers and significant weight loss, yet no SCSA was initiated as required by regulation and facility policy. The resident's medical records indicated a history of moderate protein-calorie malnutrition, adult failure to thrive, and multiple wounds, including a Stage 4 pressure injury and trauma wounds. The interdisciplinary team and registered dietitian documented ongoing concerns about the resident's nutritional status, skin integrity, and the need for increased caloric and protein intake. Despite these documented declines and interventions, the required comprehensive assessment to address the significant change in the resident's condition was not completed, as confirmed by facility policy and staff interviews.