Failure to Timely Complete Significant Change MDS Assessment After Resident Placed on Palliative Care
Penalty
Summary
A significant change in condition assessment was not completed within the required timeframe for a resident who experienced a major decline and was placed on palliative care. The resident was admitted and subsequently had physician orders initiated for palliative care due to declining health and failure to thrive. Nursing progress notes confirmed the resident's placement on palliative care, indicating a significant change in condition. However, the Minimum Data Set (MDS) assessment reflecting this significant change was not completed and signed off by the RN until 15 days after the determination of the change, and was not accepted until even later. The MDS coordinator confirmed that the assessment was not completed within the mandated 14-day period following the determination of the significant change.