Failure to Complete Significant Change MDS After Resident Transfer to Locked Unit
Penalty
Summary
Facility staff failed to complete a significant change Minimum Data Set (MDS) assessment for a resident who was moved to the memory care (locked) unit following multiple documented behavioral incidents. The resident, who had diagnoses including paranoid schizophrenia, congestive heart failure, major depressive disorder, morbid obesity, type II diabetes, mild intellectual disabilities, impulse disorder, COPD, and hypertension, was involved in several incidents of theft or loss, such as taking and consuming other residents' food and beverages. After these incidents, the resident was moved to the locked unit, and the guardian was notified. Despite the change in the resident's condition and environment, the most recent MDS assessment on record was a quarterly assessment completed prior to the move. Staff did not complete a significant change MDS within the required timeframe following the behavioral incidents and transfer to the locked unit. Additionally, the resident's care plan was not updated to address the behaviors that led to the move, and the facility did not provide a policy related to MDS assessments. Interviews with facility staff confirmed that a significant change MDS should have been completed and that the care plan had not yet been updated for the resident's behaviors.