Failure to Complete Significant Change Assessment for Resident on Hospice
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days of determining a significant change in condition for a resident who was reviewed following their death. Record review showed that the resident experienced a series of health declines, including increased confusion, becoming bedridden, dropping blood pressure, discontinuation of blood pressure medications, development of a new pressure ulcer, refusal of food and fluids due to difficulty swallowing, and increased pain. The resident's representative requested comfort care, and a physician order for hospice services was implemented. Despite these documented changes and the initiation of hospice care, there was no evidence that a SCSA was completed as required by the Resident Assessment Instrument (RAI) Manual. Interviews with the DON and MDS Nurse confirmed that the resident had multiple changes in condition and that a SCSA should have been completed prior to the resident's death, but it was not done. This failure was identified during the review of the resident's records and staff interviews.