Failure to Complete Timely Significant Change Assessments
Penalty
Summary
The facility failed to complete comprehensive significant change assessments within 14 days for two residents who experienced major changes in their conditions. For one resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and diabetes, a feeding tube was removed after the resident expressed a desire to eat by mouth and signed a dietary waiver. Although the feeding tube was discontinued per physician order, the significant change assessment was not initiated until several weeks later, as the MDS coordinator was not promptly notified of the change. In another case, a resident with moderate cognitive impairment began receiving hospice services for sarcopenia, as documented by a physician's order and hospice plan of care. However, the significant change assessment was not completed within the required timeframe because the MDS coordinator was not informed of the initiation of hospice services until days after they began. In both cases, the delay in completing the assessments was attributed to inconsistent communication from nursing staff to the MDS coordinator regarding significant changes in residents' conditions.