Failure to Complete Timely Significant Change MDS Assessment After Initiation of Anticoagulant Therapy
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) Assessment within 14 days after a significant change in a resident's condition. Record review showed that a resident was admitted with diagnoses including anoxic brain damage, cardiac arrest due to another underlying condition, and a history of venous thrombosis and embolism. The resident was not on anticoagulant therapy at the time of a quarterly MDS assessment, but physician orders later indicated the initiation of Apixaban for a history of deep vein thrombosis. Interview with the MDS staff confirmed that the initiation of anticoagulant therapy constituted a significant change in the resident's status, and acknowledged that the required Significant Change MDS Assessment was not completed within the mandated timeframe.