Failure to Complete Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess a resident within 14 days after a significant change in condition, specifically following the initiation of hospice services. The resident, who had a diagnosis including cervical disc degeneration, was admitted to hospice care as documented by a physician's order and completed hospice admission paperwork. Despite the initiation of hospice and changes to the resident's medications, there was no Significant Change Minimum Data Set (MDS) assessment completed within the required timeframe. Interviews with MDS Coordinators confirmed that a significant change MDS assessment should have been completed when hospice was started, but this was not done for the resident in question.