Failure to Complete Significant Change MDS After Hospice Initiation
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment after a resident experienced a decline in status and was initiated on hospice services. The resident had multiple diagnoses including hemiplegia, seizures, major depressive disorder, severe protein-calorie malnutrition, and anemia. A Quarterly MDS dated 07/05/24 showed a BIMS score of 5, indicating severely impaired cognition, and did not indicate that the resident had less than six months to live or that hospice services were being received. The resident’s physician orders documented admission to hospice services on 08/14/24, and the care plan initiated on 09/25/24 documented that the resident received hospice services related to a terminal diagnosis. The subsequent Quarterly MDS dated 10/04/24 documented a BIMS score of 10, indicating moderately impaired cognition, and reflected that the resident had less than six months to live and was receiving hospice services. However, the electronic medical record lacked a Significant Change MDS to identify the initiation of hospice services between 07/05/24 and 10/04/24. Administrative nursing staff acknowledged that a Significant Change MDS should have been completed when the resident was placed on hospice services. The facility reported that it did not have a specific policy and relied on CMS RAI guidelines, which require that an MDS be submitted within 14 days after determining that a significant change in a resident’s status has occurred.
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