Failure to Complete Timely Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days after a resident experienced a significant change in condition, specifically following the resident's admission to hospice care. Record review showed that the resident, an elderly male with a diagnosis of traumatic brain hemorrhage and severely impaired cognition, was admitted to hospice services, as documented in the care plan and physician's orders. However, there was no evidence that a significant change MDS assessment was completed within the required timeframe after the hospice admission. Interviews with facility staff revealed that the DON was unaware that a significant change MDS was required upon hospice admission and confirmed that the MDS nurse, who was responsible for these assessments, was unavailable at the time due to hospitalization. The facility's policy and CMS RAI guidelines both require a comprehensive assessment upon significant change in condition, including hospice enrollment, but this was not followed for the resident in question.