Failure to Complete Significant Change MDS Assessments for Residents Starting Hospice
Penalty
Summary
The facility failed to complete required significant change in condition MDS assessments when two residents began receiving hospice services. One resident with diagnoses including aphasia, dysphagia, dementia, Alzheimer’s disease, and pulmonary embolism was referred to hospice for dementia on 11/17/25, with nursing progress notes documenting the start of hospice services on 11/18/25. However, the resident’s quarterly MDS dated 12/02/25 indicated the resident was not receiving hospice services, despite hospice having already begun. Another resident with diagnoses including aphasia, dysphagia, dementia, heart disease, NSTEMI myocardial infarction, peripheral vascular disease, and hyperlipidemia was referred to hospice for a heart disease–related diagnosis on 08/25/25, with hospice admission records showing hospice services began the same day. Review of this resident’s MDS assessments showed that a significant change in condition MDS was not completed after hospice services were initiated. During an interview, the MDS Coordinator stated that a significant change in condition MDS should always be completed when a resident begins hospice services and confirmed that such assessments were not completed for these two residents.
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