Failure to Complete Significant Change Assessment After Hospice Initiation
Penalty
Summary
The facility failed to conduct a significant change assessment for one resident following a major change in condition. According to the RAI User's Manual, a comprehensive assessment must be completed within fourteen days when a resident experiences a significant change in physical or mental status. In this case, a resident with diagnoses of dementia, anemia, and depression was placed on hospice care, which constitutes a significant change in condition requiring such an assessment. Review of the resident's records showed that hospice care was initiated, but the required significant change MDS assessment was not completed within the mandated timeframe. This omission was confirmed by the Director of Nursing during an interview. The deficiency was identified through review of clinical records and staff interviews, and it was determined that the facility did not meet regulatory requirements for timely assessment following a significant change in the resident's status.