Failure to Complete MDS Assessment After Significant Change in Condition
Penalty
No penalty information released
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Summary
The facility failed to complete and submit a comprehensive Minimum Data Set (MDS) assessment following a significant change in condition for one resident. The resident experienced a decline in health status, leading to the initiation of hospice services, which was documented in the care plan. However, a review of the electronic health record revealed that no MDS entry reflecting this significant change was made within the required 14-day period. Interviews with the Director of Nursing and the MDS Coordinator confirmed that the MDS update was missed at the time the care plan was revised to include hospice services.