Failure to Complete SCSA MDS After Significant Resident Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who experienced multiple significant declines in health status. According to the Long-Term Care Resident Assessment Instrument (RAI) manual, an SCSA is required when a resident has a major decline or improvement affecting more than one area of health. The resident in question was admitted with a stage 2 pressure ulcer and no significant weight loss. Subsequent assessments documented a progression to an unstageable pressure ulcer on the sacrum, which later advanced to a stage 4 pressure ulcer with exposed bone and additional unstageable pressure ulcers on the left lower leg. The resident also experienced a significant weight loss of 25.6% over a short period. Despite these documented changes, which met the criteria for a significant change in status, there was no evidence that an SCSA MDS was completed for the resident. Staff interviews confirmed that the facility followed the RAI manual and that an SCSA should have been completed within 14 days of the significant change. Both the MDS Coordinator and the Assistant Director of Nursing acknowledged that the resident had two areas of decline and that the required assessment was not performed.