Failure to Complete Timely MDS Assessment After Significant Change in Condition
Penalty
Summary
The facility failed to complete a significant change in status assessment (MDS) within 14 days for a resident who experienced a notable decline in condition. The resident, who had a history of diabetes, hypertension, chronic kidney disease, and a right tibial fracture, was observed to have developed new symptoms including inability to lift the right arm and very weak speech, with difficulty completing sentences. Despite these changes, the most recent MDS quarterly assessment inaccurately documented the resident as having clear speech, no upper extremity impairment, and no neurological diagnosis such as aphasia. The LVN/DSD confirmed that the assessment did not reflect the resident's current status and that the change in condition had persisted for over a month without the required MDS update. Interviews with facility leadership and review of the facility's policy revealed that the policy required a significant change in status assessment MDS to be generated within 14 days of a change in condition. The CNO acknowledged that this policy was not followed. Progress notes from the physician also documented the resident's inability to move the right arm and very weak voice, further confirming the change in condition that was not properly assessed or documented in accordance with both facility policy and federal requirements.