Failure to Complete Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a comprehensive assessment following a significant change in condition for a resident who began receiving hospice services. According to the Minimum Data Set (MDS) User's Manual, a significant change in status assessment is required when a terminally ill resident enrolls in hospice and remains in the facility, with the Assessment Reference Date (ARD) to be set within 14 days of the hospice election. In this case, the resident, who had diagnoses of hypothyroidism, congestive heart failure, and high blood pressure, was admitted to hospice care, but the clinical record did not show evidence that a significant change MDS assessment was completed within the required timeframe. Review of the resident's clinical record showed a physician's order to consult hospice services, followed by an order to admit to hospice. The care plan was updated to reflect hospice services for congestive heart failure. However, there was no documentation of a significant change MDS assessment being completed within 14 days of hospice admission, as required. This was confirmed by the Registered Nurse Assessment Coordinator during an interview, acknowledging the facility's failure to meet the assessment requirement.