Failure to Complete Significant Change MDS Assessment After Resident Readmission
Penalty
Summary
The facility failed to conduct a significant change Minimum Data Set (MDS) assessment for one resident following a re-entry admission from a behavioral hospital, despite notable changes in the resident's health status. The resident had a complex medical history, including severe vascular dementia with agitation, bipolar disorder, hypertension, atrial fibrillation, and a recent wedge compression fracture requiring the use of a TLSO brace and pain management. Physician orders indicated the need for occupational therapy five times a week for 30 days, and the resident had experienced a fall, a room change, and an emergency psychiatric evaluation. Despite these significant events and changes in condition, no significant change MDS assessment or care plan update was completed after the resident's readmission. Interviews with facility staff confirmed the deficiency. The DON acknowledged that a significant change assessment and MDS update should have been completed and attributed the failure to a system issue. The MDS nurse admitted that she had not completed the required assessment or updated the care plan since the resident's return from the behavioral hospital, despite recognizing that the resident's new use of a brace, therapy, and wheelchair indicated a need for such an assessment. The lack of timely interdisciplinary review and care plan revision following the resident's significant change in condition constituted the deficiency.