Failure to Complete Timely Assessment After Significant Change in Condition
Penalty
Summary
The facility failed to complete a timely assessment for a resident who experienced a significant change in condition and was hospitalized. The resident, who had multiple diagnoses including paranoid schizophrenia, psychotic disorder with delusions, chronic kidney disease, diabetes, and dysphagia, exhibited symptoms such as needing help holding his head up, reduced strength in arms and legs, and slurred speech. Following these symptoms, the nurse practitioner was contacted and the resident was transferred to the hospital for evaluation. Upon the resident's return from the hospital, record review showed that the facility completed a Minimum Data Set (MDS) Discharge Return Anticipated assessment at the time of transfer and an MDS Entry assessment upon return. However, the facility did not complete a significant change in status assessment within 14 days of the event, as required. During interviews, the DON and MDS coordinator expressed uncertainty about whether an MDS change of condition assessment was necessary in this situation.