Failure to Complete and Transmit Significant Change MDS Assessment Timely
Penalty
Summary
The facility failed to complete and transmit a Significant Change Minimum Data Set (MDS) assessment within 14 days after determining a significant change in a resident's condition. Specifically, a resident with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, cerebral aneurysm, and chronic heart failure was admitted to the facility and later started on hospice care. The resident's clinical census and physician order indicated that hospice services began, but the MDS assessment did not reflect this change, and the Significant Change MDS was started but not completed within the required timeframe. During interviews, the resident confirmed being on hospice, while the MDS Coordinator acknowledged that the Significant Change MDS assessment was not completed as expected. The record review showed discrepancies between the resident's current care status and the documentation in the MDS, indicating that the facility did not follow the mandated timeline for updating and transmitting the assessment after a major change in the resident's health status.