Failure to Complete Significant Change Assessment After Resident Decline
Penalty
Summary
The facility failed to reassess a resident following a significant and sustained decline in their functional and mood status after a hospitalization. The resident, who previously was able to get out of bed and go outside, reported that after returning from the hospital, they could no longer get out of bed. Observations confirmed the resident remained in bed, and record review showed a marked decline in their ability to perform activities such as upper body dressing and moving in bed, as well as changes in mood and care rejection behaviors. The most recent Minimum Data Set (MDS) assessment after the resident's return indicated total dependence in several areas and new instances of care rejection, compared to the previous MDS assessment before hospitalization, which showed greater independence and no care rejection. Despite these sustained declines in multiple care areas, the facility did not complete a Significant Change in Status Assessment (SCSA) as required. Interviews with the Director of Nursing and the Corporate MDS Consultant confirmed that the changes in the resident's condition met the criteria for a SCSA, but the assessment was not performed after the 14-day period following the change. This omission was identified through interview and record review, and it was noted that the failure to complete the SCSA could result in unmet care needs and diminished quality of life for the resident.