Failure to Complete Significant Change MDS After Hospice Discharge
Penalty
Summary
The facility failed to identify a significant change in condition and complete a comprehensive Significant Change Minimum Data Set (MDS) assessment for a resident following discharge from hospice services. The resident had diagnoses of dementia, dysphagia, and aphasia, with documentation of severely impaired cognition. Despite the resident's discharge from hospice, the facility's records continued to reflect active hospice orders, and there was no timely completion of a Significant Change MDS as required. Staff interviews revealed confusion regarding the resident's hospice status, with some staff unaware of the discharge and others unable to locate relevant hospice communication materials. The resident's care plan and medical record indicated ongoing hospice involvement, even after discharge, and there was a lack of clear communication and documentation regarding the change in the resident's status. Administrative and social services staff were not fully informed or coordinated about the resident's discharge from hospice, and the facility was unable to provide a policy related to MDS procedures. This resulted in a failure to reassess the resident's needs and update care plans accordingly after a significant change in condition.