Failure to Complete Significant Change MDS Assessment After Major Resident Decline
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) as required for a resident who experienced a major decline in condition. The resident, admitted with multiple diagnoses including cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease, was discharged to the hospital and later readmitted following a stroke. Prior to the stroke, the resident was cognitively intact, able to communicate, and required only set-up assistance for eating, consuming a regular diet by mouth. After the stroke, the resident became nonverbal, unable to make needs known, developed severe cognitive impairment, and became fully dependent on staff for all activities of daily living, receiving all nutrition via gastrostomy tube feedings. Despite these significant changes in the resident's cognitive and functional status, the facility did not complete a significant change MDS assessment within the required timeframe. Staff interviews confirmed the resident's marked decline in cognition, communication, and nutritional intake following the stroke. The facility's MDS coordinator stated she did not believe the criteria for a significant change assessment were met, despite clear evidence of major declines in multiple areas of the resident's health status. This failure was identified through medical record review, staff interviews, and review of facility policy and the RAI manual.