Failure to Complete SCSA After Resident's Significant Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who experienced a major decline in condition. The resident was initially admitted without a feeding tube and required substantial to moderate assistance with eating and mobility. Following an aspiration event, the resident was hospitalized, failed a swallow evaluation, and had a feeding tube placed, resulting in a transition to NPO status. Upon return to the facility, the resident's condition had changed significantly, including increased dependence for mobility and receiving the majority of nutrition via tube feeding. Despite these changes, review of the resident's records showed that no SCSA was completed after the decline, as required by the RAI Manual when a significant change in status occurs that is not expected to resolve within two weeks. Interviews with the MDS Coordinator and the Director of Nursing confirmed that an SCSA should have been completed for this resident's decline in condition, but it was not documented in the electronic health record.