Failure to Complete Timely SCSA MDS for Resident with Significant Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe for one resident who experienced notable changes in health status. The resident, who had diagnoses including traumatic subarachnoid hemorrhage, G-tube dependence, mood disorder, and neuromuscular bladder dysfunction, was readmitted and subsequently experienced severe cognitive impairment. Despite these complex medical needs, the facility only completed a quarterly MDS assessment rather than the required comprehensive SCSA. Record reviews revealed that the resident underwent significant, unplanned weight loss over a short period, losing 57 pounds (29.4%) in 92 days. Additionally, the resident developed new and worsening pressure ulcers, including an unstageable ulcer on the sacrococcyx and a stage II pressure ulcer on the right foot. These changes represented a major decline in more than one area of the resident's health status, meeting the criteria for a significant change that would require a comprehensive reassessment and potential revision of the care plan by the interdisciplinary team (IDT). Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed that a SCSA should have been completed in response to the resident's significant weight loss and the development and worsening of pressure ulcers. The facility's own policy also indicated that a SCSA is required when there is a major decline or improvement in a resident's status affecting multiple health areas and requiring IDT review. However, the facility did not complete the SCSA as required, instead performing only a quarterly assessment.