Failure to Complete Timely Significant Change Assessment After Hospice Admission
Penalty
Summary
A deficiency occurred when the facility failed to complete a comprehensive assessment for a resident who experienced a significant change in condition, specifically upon admission to hospice care. The resident was admitted to the facility and later to hospice services, but a significant change Minimum Data Set (MDS) assessment was not completed within the required fourteen days of the hospice admission. Documentation and interviews confirmed that the MDS for the significant change was only completed nearly a month later, after the MDS office became aware of the resident's hospice status. The delay was attributed to a lack of timely notification to the MDS office regarding the resident's change in status, despite the hospice admission being documented in the clinical record and on the Ombudsman Transfer/Discharge list.