F0637

D

Failure to Complete Significant Change MDS After Multiple Hospitalizations and Treatment Changes

Dallas, Texas Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete a comprehensive, accurate Significant Change in Status Assessment (SCSA) MDS within 14 days after a resident experienced significant changes in condition and multiple hospitalizations. The resident, an older male admitted with diagnoses including metabolic encephalopathy, diabetes mellitus with hyperosmolality, hypernatremia, and acute and chronic respiratory failure with hypoxia, had an MDS dated with the type left blank and key sections either incomplete or inaccurately coded. Section C (Cognitive Patterns) showed an empty BIMS summary score and staff assessment indicating memory problems and inattention. Section J documented shortness of breath with exertion, at rest, and when lying flat, and Section K noted parenteral/IV feeding while not a resident. Section O (Special Treatments) was left empty and did not address the resident’s oxygen and IV use.

A subsequent quarterly MDS documented a BIMS score of 07, indicating severe cognitive impairment, and again noted shortness of breath in multiple positions and parenteral/IV feeding under Section K. However, Section O again indicated that the resident did not require any special treatments such as IV or oxygen, despite medical records showing orders and use of these treatments. The record showed MD orders for IV fluids, PRN albuterol nebulizer treatments, and PRN peripheral IV restarts for infiltration or extravasation. MD progress notes documented initiation of IV normal saline, completion of a BIMS with a score of 15/15 at one point, and the presence of a peripheral IV line. Interdisciplinary notes described a history of chronic respiratory failure on 2L nasal cannula O2, COPD, CKD, mood disorder, prior admissions for atypical chest pain, leukocytosis, hypernatremia, hypoxia with AMS, pulmonary embolism, aspiration pneumonia, GI bleed, AKI, and the need for thickened liquids with aspiration precautions.

The resident experienced multiple hospitalizations for atypical chest pain, hypoxia, altered mental status, leukocytosis, and later for severe hypernatremia, with documented changes in diet (thickened liquids), respiratory treatments, and IV therapy upon return to the facility. The facility’s own change of condition policy defined acute changes of condition and circumstances requiring communication and evaluation, including transfer to another healthcare community and unexpected deterioration in condition or status. Despite these significant clinical events and changes in treatment approaches, there was no significant change in condition MDS assessment in the resident’s file. Interviews with the CRN and DON confirmed that the resident had several hospitalizations and returned with clinical changes to diet, respiratory treatments, and IV therapy, and that the MDS should accurately reflect current care status and needs. The DON and ADM acknowledged that it was the responsibility of the ADON, MDSC, and DON to ensure timely and accurate completion of MDS assessments, and that the facility had not completed a change in condition assessment for this resident.

The care plan documented cognitive loss, dietician referral, prescribed diet, altered nutrition status related to weight loss, shortness of breath, risk of dehydration, oxygen therapy related to COPD, and extensive assistance needs with ADLs, but there remained no corresponding significant change MDS to capture the resident’s updated status following the hospitalizations and treatment changes. During surveyor interviews, the resident provided minimal information about recent hospitalization, oxygen treatments, and thickened water, responding only "whatever they said." The CRN initially stated that updated MDS assessments were in the EMR but was unable to produce a significant change MDS. The ADM reported that the facility had recently terminated the MDSC after observing a pattern of failing to complete timely and accurate assessments and confirmed that the DON was responsible for monitoring and ensuring that the MDS was updated. Overall, the survey findings showed that despite clear evidence of significant changes in the resident’s physical and clinical status, the facility did not complete the required significant change MDS assessment and did not accurately code existing MDSs to reflect oxygen and IV treatments and diet changes.

The facility’s written policy on change of condition emphasized the importance of recognizing and managing acute changes of condition and defined an acute change as a sudden, clinically important deviation from baseline that, without intervention, may result in complications or death. The resident’s multiple hospitalizations for serious conditions, including hypernatremia, hypoxia, and aspiration pneumonia, along with changes in diet consistency, respiratory support, and IV therapy, met the criteria for significant change. Nonetheless, the record review and staff interviews confirmed that no significant change MDS was completed, and existing MDS assessments were incomplete or inaccurate in key sections, particularly Section O for special treatments. This failure to conduct and accurately complete a significant change assessment within the required timeframe formed the basis of the cited deficiency.