F0637

D

Failure to Complete Significant Change MDS After Resident’s Functional Decline

Newton, Kansas Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to identify a significant change in condition and complete a corresponding significant change MDS assessment for one resident following a left hip fracture. The resident had dementia with severely impaired cognition, a displaced intertrochanteric fracture of the left femur, and muscle weakness. A 07/15/25 significant change MDS documented a BIMS score of four and indicated the resident required moderate assistance with transfers, maximal assistance with toileting hygiene, and was independent with bed and wheelchair mobility, with ambulation not attempted due to medical or safety concerns. A 07/21/25 Cognitive Loss/Dementia CAA documented impaired judgment and safety and the need for 24-hour nursing care in a secure setting, while the ADL Functional/Rehabilitation Potential CAA did not trigger. Subsequent MDS assessments on 09/16/25 and 10/21/25 continued to show severely impaired cognition and documented that the resident required total assistance with bed mobility, toileting hygiene, and transfers, with ambulation not attempted due to medical or safety concerns.

Despite this clear decline in functional status, the EMR lacked evidence of a required significant change in condition MDS after the resident fractured her left hip on 09/02/25. Care plans dated 01/30/25, 07/24/25, and 10/31/24 were revised on 09/25/25 to reflect that the resident, who previously could make major position changes in bed, ambulate very short distances, and required only moderate or maximal assistance for transfers and toileting, now required total assistance with two staff and a mechanical lift for transfers, total assistance for toileting, and maximal assistance for repositioning in bed. A Discharge GG Evaluation on 09/04/25 showed the resident had been independent or required only supervision/touching assistance for bed mobility, transfers, and walking prior to the decline, while a Restorative Nursing Screener/GG Evaluation on 09/17/25 documented total assistance for bed mobility, transfers, and toileting, with walking not attempted due to medical or safety concerns. A 09/25/25 health status note confirmed the resident was now a mechanical lift transfer with two staff, used incontinence products, and was dependent on a wheelchair. CNAs reported the resident required total assistance with ADLs after the hip fracture, and the Regional RN confirmed that a significant change MDS should have been completed, but none was present in the record.