Failure to Complete Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) using the Resident Assessment Instrument (RAI) process after a resident was admitted to hospice care. The resident, who had severe cognitive impairment and diagnoses including Alzheimer's disease, dementia, and traumatic brain injury, required extensive assistance with activities of daily living. Documentation showed that the resident was admitted to hospice, but the electronic medical record did not contain a significant change MDS assessment following this event. Instead, only a quarterly MDS and a death MDS were completed. During interviews, the MDS coordinator acknowledged that the significant change MDS was missed due to a miscalculation of days, and the DON confirmed the findings, stating that MDS assessments are expected to be completed in a timely manner. Facility policy requires initiation of a significant change assessment when the interdisciplinary team determines there has been a significant change in condition.