Failure to Complete Significant Change Assessments for Residents with Weight Loss and Functional Decline
Penalty
Summary
The facility failed to comprehensively assess two residents who experienced significant changes in condition, specifically regarding weight loss and functional ability, using the CMS-specified Resident Assessment Instrument (RAI) process. For one resident, medical record review revealed significant weight loss and a decline in feeding ability from independent to dependent, but the Minimum Data Set (MDS) was not updated to reflect these changes at any point during the resident's stay. Interviews with the MDS Coordinator and Administrator confirmed that the MDS record was not updated as required. Another resident experienced a weight loss of 19.73% over six months, which was documented as significant by the dietitian, and the interdisciplinary team, Medical Director, and Resident Representative were notified. However, review of the MDS showed that while changes in self-care ability were coded in subsequent assessments, there was no significant change of status assessment conducted in the MDS to reflect the weight loss and changes in activities of daily living. The MDS Coordinator acknowledged that the significant change of status assessment was missed after reviewing the resident's chart.