Failure to Complete Timely MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days following a significant change in condition for one resident who was admitted to hospice care. Record review showed that the resident, an elderly female with a primary diagnosis of senile degeneration of the brain and severely impaired cognition, was admitted to hospice services, but no significant change MDS assessment was completed within the required timeframe. The resident's care plan also did not address hospice services after her admission to hospice. Interviews with facility staff, including the MDS coordinator, DON, and Administrator, confirmed that the significant change MDS assessment was overlooked after the resident's hospice admission. The facility's policy requires a significant change in status assessment to be completed within 14 days when a resident enrolls in a hospice program, but this was not followed in this case.