Failure to Complete Significant Change MDS After Initiation of Dialysis
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident who began dialysis after being diagnosed with end-stage renal disease (ESRD). The resident's initial admission MDS did not indicate dialysis, but subsequent records showed the resident was receiving dialysis services. Despite this significant change in health status, a Significant Change MDS was not completed as required. The care plan was updated to reflect dialysis care, including instructions for staff to coordinate with the dialysis center and monitor the central venous catheter (CVC), but the required comprehensive assessment was not performed within the mandated timeframe. Further review of the resident's electronic medical record revealed missed Pre/Post Dialysis Evaluations and missing Dialysis Communication Forms on several dates. Observations showed the resident's CVC dressing was soiled and not properly secured, with visible areas of dried blood and redness on the chest. Interviews with nursing and administrative staff confirmed that a Significant Change MDS should have been completed following the initiation of dialysis, and that the MDS assessments are expected to be accurate and timely according to facility policy.