Failure to Complete SCSA MDS After Development of Pressure Ulcers
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who experienced a notable decline in health status. The resident, who had a history of vascular dementia, wheelchair dependence, and diabetes, was observed multiple times without a seating cushion in their wheelchair and was later found lying in bed. Medical records indicated the development of two facility-acquired stage II pressure ulcers in the left intergluteal region and posterior scrotum, which were still present and unhealed upon assessment by a nurse practitioner. Despite the emergence of these new stage II pressure ulcers, which meets the criteria for a significant change in status, the MDS Registered Nurse reported that a SCSA MDS was not conducted and was unaware of the pressure ulcers. The nurse also stated that SCSA MDS assessments were typically done for hospice admissions or discharges, not for pressure ulcers, and believed it was at the facility's discretion to conduct them for other changes. This lack of assessment resulted in the absence of a care plan revision to address the resident's new pressure ulcers.
Plan Of Correction
F637 - Comprehensive Assessment After Significant Change Element #1: The MDS Coordinator completed the significant change assessment for R11. The resident's care plan was reviewed and revised based on updated assessment data. R11 was assessed by the Director of Nursing and/or designee to ensure no lasting effects related to the incomplete significant change assessment. Element #2: The MDS Coordinator and/or designee initiated a review of current residents with recent hospitalizations, new diagnoses, or care plan changes in the last 30 days to identify if additional significant change assessments were warranted. Assessments will be initiated based on results of the 100% audit. Element #3: The Administrator reviewed the regulation F637. Licensed Nurses and Department Managers were provided education on significant change assessments, and the guidelines for F637. Element #4: The MDS Coordinator and/or designee will review weekly nursing reports and change-of-condition documentation to identify any missed significant change triggers for 12 weeks. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025