Failure to Complete Significant Change MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days after determining a significant change in a resident’s physical or mental condition. The resident in question was initially admitted with abnormal blood chemistry and pneumonia, and was later re-admitted from the hospital on hospice services with a diagnosis of acute kidney injury, following multiple hospitalizations in the previous month. Documentation showed that the significant change MDS was started three days after the resident’s re-admission and transition to hospice care, but as of more than two months later, the assessment remained incomplete and pending with the MDS Coordinator. Further review revealed that the resident’s care plan had not been updated to reflect the hospice admission, and the MDS Coordinator confirmed that the significant change MDS should have been completed within 14 days of initiation. The coordinator was unaware of why the assessment did not appear on their dashboard, resulting in the failure to complete the required assessment and update the care plan accordingly. Orders and documentation from the hospice company and physician confirmed the resident’s hospice status, but the necessary MDS and care plan updates were not completed as required.