Delayed Significant Change MDS Assessment After Decline in Swallowing Ability
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment within the required 14-day timeframe for a resident who experienced a notable decline in swallowing ability. The resident, admitted with dementia, was initially assessed as having no swallowing disorders and was tolerating a modified diet. However, following a physician's order for aspiration precautions and a diet change to nothing by mouth, as well as a speech therapy evaluation indicating high risk for aspiration and the need for NPO status, the facility did not initiate the required significant change MDS assessment promptly. Instead, the assessment was delayed and completed at the time of the next scheduled quarterly assessment, rather than within 14 days of the significant change in the resident's condition. Interviews with facility staff confirmed that the assessment was postponed despite the resident's worsening dysphagia and inability to take oral feedings. This delay resulted in noncompliance with regulatory requirements for timely assessment following a significant change in a resident's status.