Failure to Complete Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) for a resident who was admitted to hospice services. According to the facility's policies and the Resident Assessment Instrument (RAI) Manual, an SCSA is required within 14 days when a terminally ill resident enrolls in a hospice program. Record review showed that the resident was admitted to hospice services on 8/29/24, as confirmed by both the Director of Nursing (DON) and a Licensed Practical Nurse (LPN). However, there was no evidence that an SCSA was completed or submitted within the required 14-day timeframe following the hospice admission. Interviews with facility staff, including the DON and an LPN, confirmed their understanding that hospice admission constitutes a significant change in condition requiring an SCSA. The MDS assessment history for the resident did not show a significant change assessment within the specified period after hospice admission. The resident had a history of cerebral infarction and had been readmitted to the facility earlier in the year. The deficiency was identified through interviews, record reviews, and confirmation of the facility's policies and procedures.