Failure to Complete Significant Change MDS Assessment After Resident Decline
Penalty
Summary
A deficiency occurred when the facility failed to identify and complete a significant change Minimum Data Set (MDS) assessment for a resident who experienced a decline in condition. The resident, who had diagnoses including severe protein calorie malnutrition, vascular dementia, and difficulty walking, was initially assessed as requiring only supervision for bed mobility, transfers, and ambulation, and was at risk for skin breakdown but had no current pressure ulcers. However, subsequent documentation from physical therapy indicated a decline in the resident's functional abilities, with increased assistance needed for bed mobility, transfers, and ambulation. The resident care plan was updated to reflect these changes, but a significant change MDS assessment was not completed as required. Further review revealed that the Advanced Practice Nurse Practitioner documented a recent decline in the resident's function, including increased time spent in bed, decreased interaction, and the development of a new pressure ulcer. The DON was not made aware of the resident's decline until after the pressure ulcer developed, and the MDS Coordinator did not recognize the need for a significant change assessment until after meeting with rehabilitation staff. The MDS Coordinator acknowledged that the assessment should have been completed within 14 days of the decline, but this was not done due to oversight.