Failure to Complete Significant Change Assessment After Hospice Enrollment
Penalty
Summary
A significant change in status assessment (SCSA) was not completed for one of the sampled residents after the resident was enrolled in a hospice program. The resident, who had diagnoses including frontotemporal neurocognitive disorder and major depressive disorder, was admitted with a terminal prognosis related to end-stage Alzheimer's disease. Physician orders and hospice documentation confirmed the resident's terminal status and enrollment in hospice care. During interviews and record reviews, the Minimum Data Set Coordinator (MDSC) acknowledged that a SCSA should have been completed following the resident's enrollment in hospice but was not done. The Director of Nursing (DON) also confirmed that a SCSA is required when a resident is admitted to hospice. Facility policy states that a SCSA must be completed within 14 days of identifying a significant change, including hospice enrollment, but this was not followed in this case.