Failure to Complete Timely Significant Change MDS Assessments After Hospice Admission
Penalty
No penalty information released
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Summary
The facility failed to complete Significant Change in Minimum Data Set (MDS) status assessments within 14 days following the initiation of hospice services for three residents. Specifically, medical record reviews showed that each of the three residents, who had complex medical histories including conditions such as COPD, Alzheimer's disease, chronic respiratory failure, major depressive disorder, dementia, diabetes, and neurocognitive disorder, began hospice care but did not have the required Significant Change assessments completed within the mandated timeframe. This deficiency was confirmed during an interview with the MDS nurse, who acknowledged that the assessments were not performed as required for these residents.