Failure to Complete Significant Change MDS Assessment After Resident Health Decline
Penalty
No penalty information released
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Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident who experienced notable changes in health status. The resident, with a history of congestive heart failure and hypertension, was not coded for significant weight loss or a pressure injury on the most recent Quarterly MDS. However, after this assessment, the resident was diagnosed with a stage III pressure ulcer and later identified as having significant weight loss over a 30-day period while still receiving treatment for the pressure ulcer. Despite these significant changes, the facility did not initiate a Significant Change MDS within 14 days as required. This was confirmed by the Director of Nursing during a staff interview.