Failure to Complete Significant Change MDS After Hospice Revocation
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident who revoked hospice services following an improvement in condition. According to the Resident Assessment Instrument (RAI) manual, a significant change in status assessment (SCSA) is required when a resident discontinues hospice care. Documentation showed that the resident, who had a history of anoxic brain damage and was initially admitted to hospice, later stabilized and gained weight, leading to the revocation of hospice services. Despite this change, only a quarterly MDS assessment was completed, not the required significant change assessment. Interviews with facility staff revealed a lack of awareness regarding the requirement to complete a significant change assessment when a resident revokes hospice services. The MDS Director confirmed that the resident discontinued hospice but stated they were unaware of the need for a significant change assessment. The Director of Nursing also confirmed that the assessment had not been completed. This oversight was identified through record review, staff interviews, and review of the resident's electronic medical record.