Failure to Complete Timely Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within 14 days after determining a significant change in a resident's condition, as required by both state licensure and federal guidelines. According to the facility's policy and the Resident Assessment Instrument (RAI) Manual, an SCSA is required when there is a major decline in a resident's status that is not expected to resolve, such as changes in functional abilities, mood, or behavior. In this case, a resident experienced a notable decline in functional abilities, requiring increased assistance with mobility and transfers, and exhibited increased anxiety and behavioral symptoms, including hitting staff. The resident, who was previously ambulatory, became wheelchair-bound and showed worsening behavioral symptoms and mild depression, as documented in progress notes and MDS assessments. Despite these significant changes, the facility did not complete the required SCSA within the mandated timeframe. Interviews with facility staff, including the Social Services Director and Infection Preventionist, confirmed that the resident's decline met the criteria for a significant change and that an SCSA should have been completed according to the RAI Manual. However, the assessment was not performed as required, resulting in noncompliance with both facility policy and regulatory standards.