Failure to Complete Comprehensive Assessment After Significant Change
Penalty
Summary
The facility failed to conduct a comprehensive assessment within 14 days following a significant change in condition for one resident. The resident, who had diagnoses including acute respiratory failure with hypoxia, mechanical ventilation dependence, tracheostomy, and cerebral infarction, was admitted on 08/23/24. The quarterly Minimum Data Set (MDS) assessment indicated the resident had intact cognition and was dependent on staff for activities of daily living. On 07/09/25, the resident was decannulated following a physician's order, as documented by the respiratory therapist. However, a review of the medical record showed that a comprehensive MDS assessment was not completed after this significant change in the resident's status. This was confirmed by the Regional MDS Nurse during an interview.