Failure to Complete Timely Significant Change Assessment After Hospice Discharge
Penalty
Summary
The facility failed to complete a significant change assessment for a resident who was discharged from Hospice care after showing an improved or stabilized condition. The resident, who had diagnoses including dementia, diabetes mellitus, epilepsy, and joint stiffness, was admitted under Hospice care and later had Hospice services discontinued per physician's order. According to the MDS Coordinator, discontinuation from Hospice care is considered a significant change in status, which requires a comprehensive Minimum Data Set (MDS) assessment to be completed within 14 days of the change. However, the significant change MDS assessment for this resident was not completed and submitted until nearly two months after the discontinuation of Hospice care. The delay occurred because the MDS Coordinator was unaware of the resident's discharge from Hospice care. This late completion and submission of the MDS assessment could result in inaccurate information being used for the provision of care and delayed reporting to the Federal database, as noted by the MDS Coordinator during the interview.