Failure to Complete Significant Change Assessment After Resident's Decline
Penalty
Summary
The facility failed to complete a required Significant Change in Status Assessment (SCSA) for one resident who experienced notable changes in activities of daily living (ADL). The resident, who had a history of major joint replacement and a right femur fracture, was admitted to the facility and later sustained a fall resulting in a new right femur fracture. Following this incident, the resident was hospitalized and underwent surgical repair. Upon return to the facility, documentation indicated increased dependence in bed mobility and toileting, a change in transfer status, and a new impairment to the lower extremity. Despite these significant changes, a review of the Minimum Data Set (MDS) assessments revealed that an SCSA was not completed within the required 14-day timeframe. Staff interviews confirmed awareness of the regulatory requirements for completing significant change assessments, and it was acknowledged that the assessment should have been completed based on the resident's altered status. The MDS nurse was unable to provide a reason for the omission, and the administrator confirmed the expectation for timely and accurate completion of all MDS assessments.