Failure to Complete Significant Change Assessment After Resident's Cognitive Decline
Penalty
Summary
The facility failed to ensure that a resident who experienced a significant change in condition was comprehensively assessed within 14 days, as required. Specifically, a female resident with a history of unspecified dementia and cognitive communication deficit was readmitted to the facility and observed with increased confusion, memory loss, and altered mental status. Despite these changes, which included a decline in cognitive function and increased need for assistance with activities of daily living (ADLs), a Significant Change in Status Assessment (SCSA) was not completed. Medical records and staff interviews confirmed that the resident's cognitive status had deteriorated during her stay, with documentation of progressive dementia and acute metabolic encephalopathy. The care plan and progress notes reflected the resident's need for increased supervision and support, and staff interviews indicated that the resident required more assistance and should not have been discharged home alone. The facility's policy and CMS regulations require that significant changes in a resident's condition, especially those impacting multiple areas of health status and requiring interdisciplinary review, trigger a comprehensive assessment. Interviews with the Assistant Directors of Nursing (ADON), Nurse Practitioner (NP), and MDS nurse revealed that the expectation was for a Significant Change Assessment to be completed when a resident exhibited altered mental status or cognitive decline. The MDS nurse and DON acknowledged that the assessment was not completed as required, and that the failure could result in the resident's plan of care not being updated to reflect her current needs.