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:
The facility failed to complete an SCSA in a timely manner after a resident with COPD and chronic respiratory failure was discharged from hospice. Staff interviews and record review showed the EHR continued to list the resident as receiving hospice services after hospice had ended, and the SCSA was not completed until weeks later, after surveyor inquiry.
Failure to Complete Significant Change MDS After Hospice Election: A resident with diagnoses including a femur fracture, disorientation, and atrial fibrillation was admitted to hospice with a primary diagnosis of senile degeneration of the brain. The facility did not complete the required significant change in status MDS within 14 days of hospice admission, and a later quarterly MDS instead coded hospice. The MDS nurse said the omission was due to confusion about the payment source, and the DON stated hospice admission required a significant change MDS within 14 days.
A resident with metabolic encephalopathy and dysphagia was admitted to hospice for a terminal CVA, but the facility did not complete a significant change condition MDS within 14 days of the hospice admission. The MDS/RN acknowledged the assessment was not done timely, and the DON stated the resident should have had a significant change MDS when hospice services began.
A resident with MS, dementia, and CKD began hospice care, but the facility did not complete a significant change MDS to reflect the hospice status. The DON confirmed the resident was admitted to hospice and that no significant change MDS was completed.
Failure to complete a SCSA after a resident with COPD, CHF, dysphagia, and a PEG tube experienced increased behaviors, significant weight loss, and a hospitalization for lethargy, hypernatremia, dehydration, AKI, and acute metabolic encephalopathy. The MDSC acknowledged the decline and said the SCSA should have been completed, while the DON stated it was expected when a significant decline was identified.
Failure to complete Significant Change MDS assessments for two residents. One resident with severe cognitive impairment and major functional decline progressed from walker-assisted mobility to wheelchair use and mechanical lift transfers, while staff stated the resident had not walked for months. Another resident with a BIMS of 13 sustained a fibular neck fracture after a fall, remained painful and non-weight bearing, and continued to require a mechanical lift for transfers, but no timely SCSA was set up after the change in status was determined.
Delayed SCSA After Hospice Discharge
Penalty
Summary
The facility failed to timely complete a comprehensive assessment after a significant change in status for one resident, including failure to complete a Significant Change in Status Assessment (SCSA) after discharge from hospice services. The resident had diagnoses including COPD and chronic respiratory failure, and the most recent MDS identified that the resident was receiving hospice services. Hospice services were discontinued, but the resident’s electronic health record continued to show hospice status on the resident profile and care plan after hospice had ended. During interviews, staff confirmed the resident had been discharged from hospice and that the record still reflected hospice services. The CM stated the record should have been updated to accurately reflect the resident’s current status and that the SCSA was completed only after surveyor inquiry. The DON stated hospice discharges required updates to the care plan and clinical record and confirmed an SCSA should have been completed following the hospice discharge. Facility MDS history showed the SCSA was not completed until approximately three weeks after the hospice discharge, and the facility’s MDS policy required staff to identify significant changes, notify interdisciplinary team members, and complete the Significant Change MDS according to RAI Manual timelines.
Failure to Complete Significant Change MDS After Hospice Election
Penalty
Summary
The facility failed to complete a significant change in status MDS assessment within the required 14-day period after Resident #11 was admitted to hospice services. Resident #11 was admitted to the facility with diagnoses including fracture of the left femur with routine healing, disorientation, and atrial fibrillation, and was later admitted to hospice with a primary hospice diagnosis of senile degeneration of the brain. A review of the MDS assessments showed that no significant change in status assessment was completed after the hospice election, and instead a quarterly MDS completed later coded hospice. During interview, the MDS Nurse stated that a significant change in status MDS should be completed within 14 days of hospice admission and reported that it was not completed for Resident #11 because of confusion about the payment source. The DON stated that hospice admission was considered a significant change in status and required a significant change MDS assessment within 14 days of the hospice admission date.
Failure to Complete Significant Change Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change in condition assessment for Resident 123, who was admitted with diagnoses including metabolic encephalopathy and dysphagia and was able to make needs known and sometimes understand others. The resident was admitted to hospice on 12/26/2025 for a terminal diagnosis of cerebrovascular accident, and the record showed the resident received hospice services. However, a significant change condition MDS assessment was not completed within 14 days of the hospice admission. During interviews, the MDS/RN stated the assessment was not done timely after hospice admission, and the DON stated the resident should have had a significant change condition MDS when admitted to hospice and that this did not meet expectations.
Failure to Complete Significant Change MDS After Hospice Enrollment
Penalty
Summary
The facility failed to complete a Significant Change MDS within 14 days after a resident began hospice care. Record review showed the resident was admitted with diagnoses of MS, dementia, and CKD. The Hospice Election Form was dated 03/26/26 and showed hospice care began on 03/27/26, but the most recent MDS assessment indicated the resident was not on hospice. During an interview on 05/14/26 at 4:10 pm, the DON stated that the resident was admitted to hospice on 03/27/26 and did not have a significant change MDS to reflect hospice care.
Failure to Complete Significant Change Assessment After Major Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment for one of three sampled residents after the resident experienced a major decline in multiple areas of health status. The resident had diagnoses of COPD, CHF, dysphagia with a PEG tube, and the record showed increasing behavioral incidents, including one incident in January 2026, two in February 2026, and 12 incidents from 3/9/26 to 4/1/26. The resident also had a 7.3 lb weight loss in one month and was hospitalized for lethargy, hypernatremia, dehydration, acute kidney injury, and acute metabolic encephalopathy, requiring a four-day hospital stay and medical intervention. During interview and record review, the MDS Coordinator stated she was aware of the increased behaviors, weight loss, and hospitalization and said she should have completed a SCSA in April 2026. The DON stated the expectation was for the MDS Coordinator to complete a SCSA when the resident was identified to have a significant decline and submit it timely. The resident’s most current quarterly MDS, dated 3/12/26, still indicated only physical and verbal behavioral symptoms toward others 1 to 3 days and no weight loss within the past six months, despite the later documented decline.
Failure to Complete Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment for two residents after major changes in condition were documented in the clinical record. One resident had severe cognitive impairment on the MDS, with care plan revisions showing a change from requiring one staff assist with a walker for transfers and ambulation to requiring two staff with a mechanical sit-to-stand lift. The record also showed a progression from partial/moderate assistance with walking and use of a walker and wheelchair to no longer attempting walking and using only a wheelchair. Staff interviews indicated the resident did not walk and had not walked for months, but the restorative task had not been removed or addressed through a significant change assessment. A second resident had a BIMS score of 13 and diagnoses including viral hepatitis, diabetes mellitus, chronic pain syndrome, and cerebral infarction. After a fall in which the resident was lowered to the floor when the right knee gave out, the resident was found to have an acute non-displaced fracture of the fibular neck and was placed on non-weight bearing status until orthopedic follow-up. After the orthopedic visit, the resident was ordered weight bearing as tolerated, but progress notes documented continued significant pain, continued non-weight bearing behavior, and ongoing use of a mechanical lift for transfers with assistance from two staff members. The resident’s care plan was revised to place ambulation on hold, use a wheelchair, use a mechanical lift for transfers, and later allow a mechanical sit-to-stand lift per therapy recommendations. The MDS tracking page showed no Significant Change in Status MDS had been set up within 14 days after the change was determined. The DON acknowledged that a Significant Change in Status MDS should have been completed, and the ADON reported being told she could either change the quarterly MDS or open a new significant change assessment.
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