Failure to Complete MDS Assessment After Resident's Significant Change in Condition
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) assessment for a resident who experienced a significant change in condition. According to the facility's own policies, a significant change in status assessment should be performed when the interdisciplinary team determines that the resident meets the criteria, which include a decline that does not resolve on its own, requires staff intervention, impacts more than one area of health status, and necessitates review or revision of the care plan. In this case, the resident, who had a history of major depression, anemia, fatigue, and a major neurocognitive disorder, experienced a functional decline and weight loss. Documentation showed that the resident, previously independent in several activities of daily living, now required much more assistance, including the use of a wheelchair and help with transfers due to weakness and balance problems. Despite these changes, no significant change MDS assessment was completed within the required timeframe. Staff interviews confirmed that the resident's decline and weight loss should have triggered a change of condition MDS, but the assessment was not performed because the MDS nurse was not informed of the change. The absence of this assessment delayed the review and revision of the resident's care plan, as confirmed by both the MDS nurse and the facility administrator.