Failure to Complete Significant Change MDS After Multiple Hospitalizations and Treatment Changes
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Complete Significant Change MDS Assessment: A resident with dementia, progressive neurological conditions, and seizure disorder had an admission MDS that coded no mobility device use and independence with ADLs, but later was observed ambulating with a walker and gait belt. Quarterly MDSs still did not code walker use and showed increased ADL assistance needs, yet no comprehensive or significant change MDS had been completed. MDS coordinators said they were unaware of the walker use, believed the resident likely should not have been coded as independent, and confirmed the significant change MDS was missed.
The facility failed to complete a Significant Change MDS within the required timeframe for a resident with diabetes and COPD who was admitted to hospice. The MDS Coordinator acknowledged that the assessment was completed after the 14-day deadline.
The facility failed to complete an MDS SCSA within the required timeframe after a resident elected hospice. The resident’s hospice services began and the SCSA was completed late, and the MDS Coordinator acknowledged the assessment was probably completed after the 14-day window. CMS RAI guidance requires a SCSA when a terminally ill resident enrolls in hospice and remains in the facility.
The facility failed to complete SCSA MDS assessments within 14 days for two residents after fractures were identified. One resident with dementia, osteoporosis, AFib, HTN, and depression had a right fibular fracture after a foot/ankle injury, and another resident with dementia, TIA history, stroke history, hypothyroidism, and bilateral above-the-knee amputations had a left elbow fracture. The DON could not provide a policy or documentation for when and how a significant change assessment is completed, and the DON and an LPN confirmed the assessments were not done.
Delayed Significant Change Assessment for Hospice Election: A resident with cancer elected hospice, but the facility did not complete the SCSA within the required 14-calendar-day timeframe. The MDSC stated she did not know the assessment had to be completed within 14 days, and the DON believed they had 2 weeks to complete a significant change for hospice. The facility policy listed the MDS completion date as the 14th calendar day after determination of significant change in status.
Failure to complete timely significant change assessment: A resident with Alzheimer's disease, stroke, DM2, dysphagia, depression, heart disease, and dementia with agitation had a 5.15% weight loss in one week and developed a stage III pressure ulcer on the bilateral buttocks after an MDS showed no significant weight change and no unhealed pressure ulcers. The ADON stated she was unaware of any IDT discussions about whether a Significant Change MDS should have been completed before hospice was initiated.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change MDS assessment for a resident with a history of progressive neurological conditions, non-Alzheimer's dementia, and seizure disorder or epilepsy. The admission MDS showed a BIMS score of 8 out of 15, no upper or lower range of motion impairment, no use of mobility devices, and independence or set-up/clean-up help only for all ADLs. However, observation later showed the resident ambulating with a walker and wearing a gait belt, which differed from the admission assessment and from subsequent quarterly MDS assessments. The quarterly MDS assessments also did not code the resident as using a walker and showed increased assistance needs, including partial/moderate assistance with oral hygiene, personal hygiene, showering/bathing, and toileting hygiene, as well as supervision or touching assistance with some other ADLs. Review of the completed MDS assessments showed no comprehensive MDS, including a significant change assessment, had been completed since admission. MDS coordinators stated they were not aware the resident was using a walker, believed the resident probably should not have been coded as independent for ADLs on the admission MDS, and confirmed that a significant change MDS should have been completed but had not been.
Delayed Significant Change MDS Completion
Penalty
Summary
The facility failed to complete a Significant Change MDS within the required timeframe for Resident 2, who was admitted in 1/2026 with diagnoses including diabetes and chronic obstructive pulmonary disorder. An Election of Benefits and Informed Consent document showed the resident was admitted to hospice services on 5/24/26, but the Significant Change MDS was not completed until 6/18/26, which was 11 days after the required 14-day timeframe. On 7/22/26 at 12:27 PM, Staff 8, the MDS Coordinator, acknowledged that the Significant Change MDS completion date exceeded the required timeframe.
Late MDS SCSA After Hospice Election
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) within 14 days of a resident’s hospice election for Resident #30, who was receiving hospice services. Resident #30’s hospice certification and plan of care documented that hospice care services started on 12/31/25, and the resident’s SCSA MDS documented hospice services. The MDS Summary Page showed the 1/6/26 SCSA MDS was completed on 1/15/26. During interview, the MDS Coordinator stated that a SCSA has to be completed within 14 days of admission to hospice, including the day of admission, and acknowledged that she missed it and probably completed it late. The CMS LTC RAI User Manual states that a SCSA is required when a terminally ill resident enrolls in hospice and remains a resident in the nursing home, and that it must be completed within 14 calendar days after the determination that a significant change in status has occurred.
Failure to Complete Significant Change Assessments After Fractures
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) MDS within 14 days for two residents after changes in condition. Resident 2 was admitted with diagnoses including osteoporosis, dementia with psychotic disturbance, depression, atrial fibrillation, hypertension, and dizziness/giddiness. Progress notes dated 6/30/26 documented an injury to the resident’s right foot/ankle, and x-ray findings showed a right fibular fracture. The record review showed no SCSA MDS completed within 14 days of that fracture. Resident 3 was admitted with diagnoses including mental disorders due to known physiological conditions, transient ischemic attack, cerebral infarction without residual deficits, hypothyroidism, bilateral above-the-knee amputations, and dementia. Progress notes dated 12/1/25 documented an x-ray revealing a fracture to the left elbow. The clinical documentation showed no significant change assessment completed within 14 days of that change in condition. The DON was unable to provide a policy or documentation on when and how a significant change is to be done on an MDS, and an interview with the DON and an LPN confirmed that the SCSA MDS was not completed after either resident’s fracture and should have been done.
Delayed Significant Change Assessment for Hospice Election
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) through the Resident Assessment Instrument (RAI) process within the required time frame for a resident who elected hospice benefits. Resident #11, who had diagnoses including cancer, was admitted to hospice effective 2/20/26. The resident’s MDS showed that the SCSA dated 3/4/26 was completed on 3/10/26, which was not within 14 calendar days of the hospice election and should have been completed by 3/6/26. During the survey, the resident was observed in a wheelchair and stated that hospice was going well. The MDS Coordinator stated that a significant change for hospice should be done within 14 days of going on hospice and acknowledged that this resident’s MDS was dated 3/4/26, but said she did not know it had to be completed within 14 days. The DON stated she believed they had 2 weeks to complete a significant change for hospice, and the Regional LNHA stated the MDSC misinterpreted the guidelines for opening an MDS versus completion of the MDS. The facility policy titled MDS Completion and Submission Timeframes stated the MDS completion date as the 14th calendar day after determination of significant change in status.
Failure to Complete Timely Significant Change Assessment
Penalty
Summary
The facility failed to timely complete a significant change assessment for a resident who experienced a major decline in status after a severe weight loss and the development of pressure ulcers. Resident #50 had diagnoses including Alzheimer's disease, stroke, type two diabetes, difficulty swallowing, depression, heart disease, and dementia with agitation. An admission/Medicare 5-day MDS assessment showed the resident was severely cognitively impaired, with no or unknown significant weight changes and no unhealed pressure ulcers at that time. The resident's record later showed a weight of 203.9 pounds on 05/19/26 and 193.4 pounds on 05/26/26, a 5.15% loss in one week. A weekly wound observation dated 05/25/26 documented that the resident had acquired a stage III pressure ulcer on bilateral buttocks. The Facility RAI 3.0 User's Manual states a significant change assessment should be completed by the 14th calendar day after the facility determined the change occurred. During interview, the ADON stated she was unaware of any IDT discussions to determine whether a Significant Change MDS should have been completed prior to initiation of hospice in July 2026.
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