Failure to Complete Significant Change in Status Assessment After Resident Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced a notable decline in activities of daily living (ADLs). According to the facility's policy, an SCSA must be conducted when the interdisciplinary team (IDT) determines that a resident has undergone a significant change, defined as a major decline or improvement affecting more than one area of health status and requiring care plan review. The resident in question, admitted with dementia, initially required partial assistance with some ADLs and supervision for others. Subsequent assessments showed a marked decline, with the resident becoming dependent on staff for multiple ADLs, including upper body dressing, rolling, transferring, and wheelchair mobility. Despite this decline, the medical record did not show that an SCSA was completed after the change in the resident's condition. During an interview, consulting staff acknowledged that after a fall with injury, the IDT believed the decline would be self-limiting. However, by the time of a later assessment, the resident had not improved and was no longer receiving therapy, with continued decline in more than two ADL areas. Staff confirmed that an SCSA should have been completed at that time, but it was not.