Failure to Timely Complete MDS Assessments After Significant Change
Summary
The facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments within the federally required timeframe following a significant change in condition for five residents who enrolled in hospice care. For each resident, the Electronic Health Record and Medicare Hospice Election forms documented the date hospice services began, but the corresponding Significant Change MDS assessments were completed and dated well beyond the 14-day requirement outlined in the 2024 Resident Assessment Instrument (RAI) Manual. The delays ranged from 18 to 25 days after hospice election, exceeding the federal guidelines for timely assessment. This deficiency was identified through clinical record review and staff interviews, which confirmed that the facility did not have a policy regarding MDS Assessments and relied solely on the RAI manual. The residents involved were all documented as having a significant change in condition due to enrollment in hospice care, which should have triggered a timely comprehensive assessment. The lack of timely MDS completion was observed for all five residents reviewed for MDS Assessments.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with chronic respiratory failure with hypoxia and dementia was started on hospice care per physician order and care plan documentation, but the facility did not complete the required significant change in condition/status MDS assessment within 14 days of this change. The MDS coordinator and CNO both acknowledged that the significant change MDS should have been completed but was not, resulting in the resident’s status not being accurately reflected in the assessment.
A resident with dementia, major depressive disorder, anxiety, and bipolar disorder was admitted to hospice, but the facility failed to complete a required Significant Change MDS at the time of hospice admission. The resident had severely impaired cognition per prior MDS and CAA documentation and was receiving daily antipsychotic medication. The care plan only reflected hospice-provided extra bathing and did not include other hospice services, despite physician orders for hospice to evaluate and treat. Administrative nurses acknowledged that while a significant change MDS had been completed earlier for a different health status change, no new significant change MDS was done when hospice services began, contrary to the facility’s MDS transmission policy.
A resident with dementia and a left hip fracture experienced a marked decline in ADLs, changing from being independent or needing only supervision/touching assistance with bed mobility, transfers, toileting, and short-distance ambulation to requiring total assistance, use of a mechanical lift with two staff for transfers, and dependence on a wheelchair. Care plans and GG evaluations were revised to reflect this decline, and CNAs reported the resident now needed total assistance with ADLs. Despite these documented changes in condition and function, the EMR contained no significant change MDS, and a Regional RN confirmed that such an assessment should have been completed.
A resident with multiple complex conditions, including hemiplegia, seizures, major depressive disorder, severe protein-calorie malnutrition, and anemia, was admitted to hospice, and the care plan documented hospice services related to a terminal diagnosis. The earlier quarterly MDS did not show hospice or a prognosis of less than six months to live, while the later quarterly MDS did, but no Significant Change MDS was completed in the interval to capture the initiation of hospice services. Administrative nursing staff acknowledged that a Significant Change MDS should have been done, and the facility reported relying on CMS RAI guidelines, which require submission of an MDS within 14 days of determining a significant change in status.
A resident experienced a major decline in condition that led to hospice referral and admission, with hospice services initiated and documented by hospice staff and family signatures. Despite clear evidence that the resident’s condition had changed and hospice care had started, facility staff did not complete a Significant Change in Status Assessment (SCSA) MDS within the required 14-day timeframe. During interviews, MDS staff acknowledged the resident’s hospice status and confirmed that a change in condition MDS was expected but was not completed.
A resident with severe cognitive impairment, dysphagia, adult failure to thrive, multiple pressure ulcers, and total dependence for ADLs experienced a 5.8% unplanned weight loss in 30 days while not on a physician-prescribed weight-loss regimen. Facility records and MDS data showed poor oral intake, frequent incontinence, unhealed Stage 3 and Stage 4 pressure ulcers, and ongoing nutritional concerns, with the resident receiving a mechanically altered diet and nutritional supplements. Staff, including nursing, wound care, and dietary, acknowledged the resident’s poor intake and that a 5% or greater unplanned weight loss in 30 days is significant and requires intervention, yet the facility did not initiate or complete a Significant Change in Status Assessment (SCSA) in the MDS within the required 14-day timeframe.
Failure to Complete Significant Change MDS After Initiation of Hospice Care
Penalty
Summary
The facility failed to complete a significant change in condition or status assessment MDS within 14 days after a resident began hospice care, resulting in an inaccurate reflection of the resident’s status. The resident was admitted with multiple diagnoses, including chronic respiratory failure with hypoxia and dementia. A physician order dated 2/19/26 documented end-of-life care with hospice services, and the resident’s care plan also documented that hospice care started on that date. Despite this documented change in condition and care approach, the facility did not complete the required significant change MDS assessment within the mandated timeframe. On 3/31/26, the MDS coordinator acknowledged that the significant change assessment had not been completed and stated it should have been. On 4/1/26, the CNO similarly stated that the significant change in condition or status assessment MDS should have been completed within 14 days of the start of hospice care and had not been. This deficient practice had the potential for negative outcomes if the resident was not assessed and cared for or monitored due to inaccurate assessments.
Failure to Complete Significant Change MDS Upon Hospice Admission
Penalty
Summary
The facility failed to identify a significant change in condition and complete a comprehensive Significant Change MDS when a resident was admitted to hospice services. The resident had documented diagnoses of dementia, major depressive disorder, anxiety, and bipolar disorder. A Significant MDS dated 12/28/25 showed a BIMS score of 99 with a staff interview indicating severely impaired cognition, and a Cognitive Loss/Dementia CAA dated 01/02/26 documented dementia and daily antipsychotic use. The care plan included an intervention for hospice to provide extra bathing on Mondays and Thursdays but lacked documentation of other hospice services. Physician orders dated 01/21/26 directed hospice of the family's choice to evaluate and treat, and the resident was observed seated in a Broda chair at the dining room table while a CNA attempted to assist with breakfast. Administrative staff interviews revealed that the required Significant Change MDS was not completed at the time of the resident's admission to hospice. One administrative nurse stated she had completed a significant change MDS prior to the resident's hospice admission and acknowledged she should have completed another significant MDS after hospice admission. Another administrative nurse confirmed that the significant change MDS was not completed when the resident was admitted to hospice, clarifying that the earlier significant change MDS had been done for a prior significant change in health status. The facility's policy on Electronic Transmission of the MDS, effective 10/2025, stated that MDS assessments, including significant change assessments, would be transmitted per state and federal guidelines, but this was not followed for the hospice admission event.
Failure to Complete Significant Change MDS After Resident’s Functional Decline
Penalty
Summary
The deficiency involves the facility’s failure to identify a significant change in condition and complete a corresponding significant change MDS assessment for one resident following a left hip fracture. The resident had dementia with severely impaired cognition, a displaced intertrochanteric fracture of the left femur, and muscle weakness. A 07/15/25 significant change MDS documented a BIMS score of four and indicated the resident required moderate assistance with transfers, maximal assistance with toileting hygiene, and was independent with bed and wheelchair mobility, with ambulation not attempted due to medical or safety concerns. A 07/21/25 Cognitive Loss/Dementia CAA documented impaired judgment and safety and the need for 24-hour nursing care in a secure setting, while the ADL Functional/Rehabilitation Potential CAA did not trigger. Subsequent MDS assessments on 09/16/25 and 10/21/25 continued to show severely impaired cognition and documented that the resident required total assistance with bed mobility, toileting hygiene, and transfers, with ambulation not attempted due to medical or safety concerns. Despite this clear decline in functional status, the EMR lacked evidence of a required significant change in condition MDS after the resident fractured her left hip on 09/02/25. Care plans dated 01/30/25, 07/24/25, and 10/31/24 were revised on 09/25/25 to reflect that the resident, who previously could make major position changes in bed, ambulate very short distances, and required only moderate or maximal assistance for transfers and toileting, now required total assistance with two staff and a mechanical lift for transfers, total assistance for toileting, and maximal assistance for repositioning in bed. A Discharge GG Evaluation on 09/04/25 showed the resident had been independent or required only supervision/touching assistance for bed mobility, transfers, and walking prior to the decline, while a Restorative Nursing Screener/GG Evaluation on 09/17/25 documented total assistance for bed mobility, transfers, and toileting, with walking not attempted due to medical or safety concerns. A 09/25/25 health status note confirmed the resident was now a mechanical lift transfer with two staff, used incontinence products, and was dependent on a wheelchair. CNAs reported the resident required total assistance with ADLs after the hip fracture, and the Regional RN confirmed that a significant change MDS should have been completed, but none was present in the record.
Failure to Complete Significant Change MDS After Hospice Initiation
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment after a resident experienced a decline in status and was initiated on hospice services. The resident had multiple diagnoses including hemiplegia, seizures, major depressive disorder, severe protein-calorie malnutrition, and anemia. A Quarterly MDS dated 07/05/24 showed a BIMS score of 5, indicating severely impaired cognition, and did not indicate that the resident had less than six months to live or that hospice services were being received. The resident’s physician orders documented admission to hospice services on 08/14/24, and the care plan initiated on 09/25/24 documented that the resident received hospice services related to a terminal diagnosis. The subsequent Quarterly MDS dated 10/04/24 documented a BIMS score of 10, indicating moderately impaired cognition, and reflected that the resident had less than six months to live and was receiving hospice services. However, the electronic medical record lacked a Significant Change MDS to identify the initiation of hospice services between 07/05/24 and 10/04/24. Administrative nursing staff acknowledged that a Significant Change MDS should have been completed when the resident was placed on hospice services. The facility reported that it did not have a specific policy and relied on CMS RAI guidelines, which require that an MDS be submitted within 14 days after determining that a significant change in a resident’s status has occurred.
Failure to Complete Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) MDS within 14 days after determining a resident had a major decline in condition and required hospice services. The resident was admitted on 11/07/25 and subsequently had a physician order on 01/16/26 for a hospice referral, followed by an order on 01/22/26 to admit the resident to hospice. A hospice admission agreement was signed by the resident’s family member on 01/17/26, and a hospice nurse documented a start-of-care visit on the same date. Despite these documented indicators that the resident’s condition had declined and hospice services had begun, record review showed no significant change MDS assessment was completed within the required 14-day timeframe. During interview, the MDS Coordinator and Regional MDS Coordinator confirmed the resident was placed on hospice services on 01/17/26, that no change in condition MDS assessment was completed, and that staff were expected to complete such an assessment within 14 days after identifying a change in condition.
Failure to Complete SCSA After Significant Unplanned Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to complete a Significant Change in Status Assessment (SCSA) in the MDS within 14 days after a resident experienced a significant, unplanned weight loss. The resident had a documented weight decrease from 117.4 lbs to 110.6 lbs over a 30-day period, a 5.8% loss, which met both facility and RAI criteria for significant weight loss requiring comprehensive reassessment and an SCSA. Despite this documented change, there was no evidence that an SCSA was initiated or completed within the required timeframe. The resident had multiple complex medical conditions, including neurocognitive disorder with Lewy bodies, Parkinson’s disease, adult failure to thrive, dysphagia, anorexia, and cognitive communication deficit. The admission and subsequent quarterly MDS assessments documented severely impaired cognitive skills, total dependence for ADLs and mobility, frequent bladder and bowel incontinence, unhealed pressure ulcers (including Stage 3 and Stage 4 ulcers), and weight loss of 5% or more in one month or 10% in six months while not on a physician-prescribed weight-loss regimen. The resident was on a mechanically altered diet, later changed to puree, and was receiving nutritional supplements and an antidepressant. Staff interviews confirmed that the resident had poor oral intake, was non-verbal, required feeding assistance and encouragement to eat, and had multiple pressure ulcers and impaired mobility. The wound nurse and wound NP described the resident as frail, thin, underweight, and at risk for impaired wound healing, and the dietitian stated that unplanned weight loss of 5% or more in 30 days is significant and requires intervention. The RN unit manager stated that significant weight loss should prompt notification of the dietitian and physician and documentation in progress notes but did not recall this resident’s significant weight loss. The DON stated that monitoring weight is the responsibility of all disciplines and deferred to the dietitian regarding whether a 5% weight loss constituted a significant change, yet no SCSA was completed despite the documented significant, unplanned weight loss and associated clinical indicators.
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