Failure to Complete Significant Change Assessment After Resident Fall and Hospitalization
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. The resident was admitted with multiple diagnoses, including polyosteoarthritis, restless leg syndrome, essential hypertension, anemia, osteoporosis, depression, a history of falls, spinal stenosis, and orthopedic aftercare following a contusion of the right hip. After admission, the resident sustained a fall, was transferred to the hospital, underwent surgical treatment for a left wrist fracture, and returned to the facility with a left-hand brace, sling, non-weight bearing status for the left upper extremity, and pain medication. Despite these significant changes in condition, the medical record did not include a completed Significant Change in Condition Comprehensive Assessment/Minimum Data Set (MDS). The Care Plan and MDS Coordinator confirmed that the required assessment had not been completed.