Failure to Complete Timely Significant Change MDS Assessments for Residents with Hospice Status Changes
Penalty
Summary
The facility failed to ensure timely completion of Significant Change in Status Minimum Data Set (MDS) assessments for three residents who experienced significant changes in their hospice care status. For one resident, the MDS assessment was completed late after the resident was admitted to hospice care, as confirmed by the MDS Coordinator. Another resident was discharged from hospice services, but no Significant Change in Status MDS was completed following the end of hospice care, as verified by the Director of Nursing. Additionally, a third resident was admitted to hospice care, but no Significant Change in Status MDS was completed within the required 14-day period following the change. These findings were confirmed through interviews with facility staff and review of resident records, which documented the changes in hospice status and the lack of timely or completed MDS assessments as required.