Failure to Complete Timely MDS Assessment After Significant Change in Condition
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) assessment for a significant change in status within the required timeframe for one resident. The resident was initially admitted with multiple diagnoses, including dementia, metabolic encephalopathy, diabetes mellitus, and had a gastrostomy feeding tube. Upon readmission, there was a recognized change in condition, specifically the presence of a gastrostomy feeding tube, but the required MDS change of condition assessment was not completed within 14 days as mandated. Record review showed that no MDS assessments addressing the change in condition were available between early February and early May, despite the resident's readmission and altered clinical status. The MDS nurse confirmed during interview and record review that the assessment should have been completed within the specified timeframe but was not. Facility policy required a comprehensive assessment for significant changes in a resident's condition, in accordance with OBRA regulations, but this was not followed in this instance.