Failure to Complete Significant Change MDS Assessments After Resident Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for two residents who experienced declines in multiple areas of health status. For one resident with dementia and a history of pressure ulcers, the clinical record showed a new Stage 2 pressure ulcer, a decline in functional mobility, and significant weight loss over several months. Despite these changes, which included increased assistance needs for eating, bed mobility, and transfers, as well as the development and worsening of pressure ulcers, no SCSA MDS was completed as required. Another resident with early onset Alzheimer's disease, diabetes, and epilepsy experienced a hospitalization for altered mental status and subsequently returned to the facility with increased dependence on staff for activities of daily living (ADLs) and eating. This resident also had a notable weight loss following hospitalization and required more assistance with meals. The quarterly MDS assessment documented declines in four functional mobility areas and weight loss, but again, a significant change MDS was not completed. Interviews with facility staff revealed a lack of understanding regarding the criteria for initiating a significant change MDS assessment. One LPN indicated she was unaware that weight loss plus a decline in one ADL met the criteria for a significant change, and that she relied on the dietician to code weight loss in the MDS. The facility's interdisciplinary team, including the dietician and nursing staff, did not effectively communicate or recognize the need for a significant change assessment despite regular risk meetings and documentation of the residents' declines.