Failure to Complete Significant Change Assessment After Resident Decline
Penalty
Summary
A deficiency occurred when the facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced notable declines in health status. The resident, admitted with a diagnosis of Cerebral Vascular Disease, initially required moderate assistance with activities of daily living (ADLs), was continent of bowel and bladder, and weighed 250 lbs. Over the course of several months, the resident's condition declined, requiring maximum assistance for ADLs, becoming occasionally incontinent of bowel and bladder, and experiencing a significant weight loss to 234 lbs. This decline was not self-limiting and affected multiple areas of the resident's health. Despite these changes, a review of the medical record showed that the required SCSA was not completed after the resident's decline. The MDS Nurse confirmed that, according to the Resident Assessment Instrument (RAI) manual, a SCSA should have been completed when the quarterly MDS assessment was performed, but it was not. The failure to complete the SCSA occurred even though the resident met the criteria for a significant change in status, as outlined in the RAI manual.