Failure to Complete Significant Change MDS After Resident Decline
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident who experienced a notable decline in condition following a fall and subsequent hip fracture. After the resident fell and sustained a hip fracture, she underwent surgery and returned from the hospital in a non-ambulatory state. Despite this significant change in her mobility and care needs, the staff member responsible for MDS assessments completed a Quarterly MDS instead of a Significant Change MDS, as required by the Resident Assessment Instrument (RAI) guidelines. The staff member acknowledged during an interview that a Significant Change MDS should have been completed and that she would refer to the RAI guidelines in the future to determine the appropriate assessment. Record review showed that prior to the fall, the resident was independent with ambulation and required only supervision or substantial assistance for other activities of daily living. After the incident, the resident became dependent on staff for transferring, toileting, bathing, dressing, and personal hygiene, and was coded for wheelchair use. The facility's policy for MDS assessments is based solely on the RAI manual, with no additional internal policies in place. The failure to complete the required Significant Change MDS assessment meant that the resident's substantial decline in function was not formally identified through the MDS process.