Failure to Complete Timely MDS Assessment After Significant Change
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) assessment within 14 days following a significant change in a resident's condition. Specifically, a resident was admitted to hospice services, which constitutes a significant change requiring an updated MDS assessment. Record review showed that the MDS significant change assessment was initiated ten days after the resident's admission to hospice but remained incomplete more than three weeks after the significant change occurred. During a phone interview, the MDS Coordinator confirmed both the resident's admission to hospice and that the significant change assessment was still in process well past the required timeframe. The Coordinator acknowledged that the MDS assessment should have been updated within 14 days of the significant change, and that the electronic records had not been updated in a timely manner. Facility leadership and relevant staff were informed of these findings during the exit conference.