Failure to Complete Significant Change Assessment After Resident Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced notable declines in multiple areas of functioning. Review of the Minimum Data Set (MDS) assessments showed that the resident went from requiring maximum assistance with dressing, being independent with bed mobility, and needing maximum assistance with transfers and ambulation, to being dependent in dressing, bed mobility, and transfers, and unable to ambulate. The resident also became always incontinent of bowel, indicating a significant change in status across several domains. Despite these changes, only a quarterly MDS was completed instead of a significant change MDS as required. Interviews and observations confirmed the resident's increased dependence, with nursing assistants needing to provide two-person assistance for transfers and full assistance for bed mobility and toileting. The registered nurse responsible for MDS completion acknowledged that the resident's decline should have triggered a significant change assessment, as the changes were not expected to resolve within two weeks and affected multiple areas of health status. Facility policy and CMS guidelines both require a comprehensive assessment in such cases, but this was not done, resulting in the deficiency.