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
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Failure to complete timely SCSA for two residents: one resident had a decline in ADL function after hip fracture repair and return from hospital care, with MDSs showing pain, opioid use, and dependence for dressing, toileting, transfers, and ambulation, while another resident enrolled in hospice had an MDS completed beyond the required timeframe. Survey staff and the DON confirmed the missed assessments and that the facility followed CMS/RAI guidance for MDS timing.
A resident with diagnoses including an unstageable sacral pressure injury, functional quadriplegia, DM2, and COPD declined from needing substantial/maximal assistance with several ADLs to being dependent for all ADLs, including eating, hygiene, dressing, toileting, bathing, and transfers. The resident and CNA both confirmed the decline, and the DON, Regional Nurse Consultant, MDS Lead, and MDS Coordinator acknowledged the resident met criteria for a significant change in status assessment, but it was not completed.
A resident with lung cancer, HTN, COPD, and moderate cognitive impairment on hospice had a change in hospice provider, but the MDS Coordinator did not complete the required significant change MDS within the 14-day timeframe. The MDS record showed no significant change assessment after the hospice switch, and the MDS Coordinator, DON, and ADM all acknowledged the assessment was expected to be completed timely.
A resident was admitted to hospice, but the facility did not complete a significant change MDS within the required timeframe. The quarterly MDS and care plan did not reflect hospice services, and the DON stated she did not realize a significant change MDS was needed when the resident entered hospice care.
A resident with stroke, aphasia, and multiple chronic conditions made repeated suicidal statements and was sent out for emergency psychiatric evaluation several times. Although the care plan addressed suicidal thoughts and the DON confirmed the resident had been suicidal since admission, the MDS assessments reviewed did not reflect the significant change in mental condition. Staff and leadership acknowledged the resident’s ongoing suicidal ideation, but the required comprehensive significant change MDS was not completed.
A resident with CHF and CKD 3b had a major decline after a fall with a closed hip fx and surgical repair. The resident went from needing partial to moderate assist with transfers and limited ambulation to requiring a Hoyer lift, maximal assist with eating and transfers, no longer ambulating, and being incontinent of bowel and bladder, but the facility did not complete a comprehensive Significant Change in Status Assessment; the RNAC confirmed the omission.
Failure to Complete Timely Significant Change Assessments
Penalty
Summary
The facility failed to complete a significant change in status assessment within 14 days after determining that two residents had experienced significant changes in condition. For Resident #3, the record showed diagnoses including dementia, muscle weakness, gait and mobility abnormalities, anxiety, osteoporosis, and a fractured hip. After hospitalization for hip fracture repair and return to the facility for skilled care, the resident’s MDSs documented surgical intervention for the hip, skilled care and surgical wound care, pain with opioid use, and a decline to dependence for dressing, toileting, personal care, transfers, and ambulation. Survey staff noted the resident’s hip fractures and decline in function would warrant a significant change, but the facility completed a Medicare 5-day assessment instead of a significant change assessment. For Resident #1, the MDS documented hospice services, and the census line and health status note showed hospice enrollment. The RAI manual cited in the report states that a significant change assessment is required when a terminally ill resident enrolls in hospice, with the assessment completion date no later than 14 calendar days after the determination date. The resident’s hospice enrollment was identified on 3/31/26, but the assessment completion date was 4/17/26. The DON stated the facility did not have an MDS policy and followed CMS and RAI guidance for when an MDS was due or indicated.
Failure to Complete Significant Change in Status Assessment for ADL Decline
Penalty
Summary
The facility failed to complete a comprehensive significant change in status assessment for a resident whose ADL function declined. The resident was readmitted with diagnoses including an unstageable sacral pressure injury, functional quadriplegia, type 2 diabetes, and COPD. On the admission MDS, the resident had a BIMS score of 14 out of 15 and required substantial/maximal assistance for several ADLs, while being dependent for toileting hygiene, showering/bathing, lower body dressing, and putting on and taking off footwear, as well as requiring substantial/maximal assistance with multiple bed mobility and transfer tasks. The quarterly MDS later showed the resident remained cognitively intact with a BIMS score of 13 out of 15 but had declined to dependence for all ADLs, including eating, oral hygiene, dressing, hygiene, toileting, bathing, and footwear, and was dependent for rolling in bed and chair/bed-to-chair transfers. The care plan noted a decrease in ADL function related to physical limitations and decreased motivation. The resident stated he needed assistance with everything because he could no longer move his hands or arms and could not manage a spoon independently, and a CNA confirmed he was totally dependent for all ADLs. The DON, Regional Nurse Consultant, MDS Lead, and MDS Coordinator reviewed the record and confirmed the resident had declined in more than two ADLs from admission to quarterly assessment and met criteria for a significant change in status assessment, but one had not been completed.
Failure to Complete Significant Change MDS After Hospice Change
Penalty
Summary
The facility failed to complete a significant change MDS assessment within 14 days after a significant change in condition for one resident. Resident #1 was a male admitted with diagnoses including malignant neoplasm of the lower lobe of the left bronchus or lung, hypertension, and COPD. His care plan reflected hospice services for senile degeneration of the brain, and his quarterly MDS showed a BIMS score of 09 with moderate cognitive impairment and hospice care while at the facility. A physician order dated 06/04/2026 showed the resident was admitted to another hospice company due to the malignant neoplasm diagnosis, but the EHR contained no significant change assessment after the hospice change. The MDS Coordinator stated she was responsible for completing the significant change assessment by 06/17/2026 and did not know how she missed it. The DON and ADM both stated it was expected that the significant change MDS be completed within 14 days of the hospice company change.
Failure to Complete Significant Change MDS for Hospice Admission
Penalty
Summary
The facility failed to complete a significant change MDS assessment within 14 days after determining that Resident #5 had a significant change in condition when she was admitted to hospice services. Record review showed Resident #5 was admitted to the facility with hospice as her primary payer, and an active order dated 06/10/26 indicated she was to be admitted to hospice services. The resident’s most recent quarterly assessment was completed on 06/02/26, and the EHR showed no significant change MDS assessment in the last year. The assessment also did not reflect hospice services, and the care plan completed on 06/07/26 did not mention hospice. During interview, the DON stated she was responsible for completing MDS assessments and used the RAI manual as her guide. She stated significant change MDS assessments were to be completed within 14 days of the change and acknowledged she did not realize a significant change MDS was needed for Resident #5 entering hospice care. The ADM stated the DON was responsible for MDS completion and that failure to complete the assessment within the allotted time could negatively affect the resident’s care.
Failure to Complete Significant Change MDS for Suicidal Ideation
Penalty
Summary
The facility failed to complete a comprehensive MDS significant change assessment within 14 days after it determined, or should have determined, that Resident #2 had a significant change in mental condition. Resident #2 was a male resident with a history of stroke, hypertension, BPH, diabetes mellitus, hyperlipidemia, thyroid disorder, and aphasia. His admission MDS showed a BIMS score of 14 with no reported depressed mood, and a later quarterly MDS showed a BIMS score of 12 with the same mood interview responses coded as not depressed or lacking interest. Record review showed repeated suicidal ideation and related behavioral events beginning with a nurse progress note documenting that the resident told the IDT he planned suicide by jumping out a window, wrapping cords around his neck, and rolling out of bed. He was sent to the ER for suicidal ideation. Additional notes documented further suicidal statements and emergency evaluations, including a psychiatric referral, another episode where he told a psychiatrist he wanted to kill himself and was sent to a psychiatric hospital, another event where 911 was called after he said he wanted to kill himself, and a later event where he called 911 and stated he planned to kill himself at 6 p.m. that day. The resident’s care plan reflected suicidal thoughts and ongoing suicidal ideations, but the MDS assessments reviewed did not reflect the change in mental condition. The DON stated the resident had been suicidal since admission and confirmed multiple suicidal statements and hospital transfers, while the MDS staff stated they were responsible for accurate assessments and that the assessments should reflect the care provided. The Administrator stated there was nowhere to put suicidal ideation on the MDS mood section and said the care plans were based on the MDS data. The facility policy stated the IDT was to follow RAI guidelines for MDS processes and use the RAI manual to support coding and other MDS procedures.
Failure to Complete Significant Change in Status Assessment After Major Decline
Penalty
Summary
The facility failed to complete a comprehensive Significant Change in Status Assessment using the MDS after Resident 50 experienced a major decline in physical functioning. The resident was admitted with chronic diastolic heart failure and CKD stage 3b, and the admission MDS documented moderate cognitive impairment with a BIMS score of 10, set-up assistance for eating, partial to moderate assistance with transfers, ambulation up to 10 feet with partial to moderate assistance, frequent bladder incontinence, and occasional bowel incontinence. After a fall that resulted in a closed left hip fracture and hospital transfer, the resident returned to the facility following surgical repair. Physician orders then directed use of a Hoyer lift for transfers and a Broda chair when out of bed. The quarterly MDS documented further decline, including a BIMS score of 9, maximal assistance with eating and transfers, no longer ambulatory status, and total incontinence of bladder and bowel. The clinical record contained no documentation that the facility completed a comprehensive Significant Change in Status Assessment despite the resident’s decline affecting mobility, transfers, eating ability, continence, and functional independence, and the RNAC confirmed the assessment was not completed.
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