Failure to Complete Timely MDS Significant Change Assessment After Resident Status Change
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) within 14 days for a resident who experienced a significant change in condition. Specifically, the resident was admitted with multiple pelvic fractures and post-surgical aftercare, and later received a new order allowing weight bearing as tolerated following an orthopedic follow-up. Despite this significant change, the MDS nurse confirmed that no SCSA was completed within the required timeframe, and the last MDS assessment on record was a Medicare 5-day assessment related to the change in weight bearing status. Interviews and record reviews revealed that the MDS nurse was aware of the new order and the requirement for a significant change assessment but did not complete it as mandated. The facility's policies and job descriptions require timely and accurate completion of MDS assessments, and professional guidelines specify that a SCSA must be completed within 14 days of determining that criteria are met. The administrator stated an expectation for timely and accurate MDS completion, but this was not met in this instance.