F0637

D

Failure to Complete Significant Change MDS Upon Hospice Admission

Pittsburg, Kansas Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The facility failed to identify a significant change in condition and complete a comprehensive Significant Change MDS when a resident was admitted to hospice services. The resident had documented diagnoses of dementia, major depressive disorder, anxiety, and bipolar disorder. A Significant MDS dated 12/28/25 showed a BIMS score of 99 with a staff interview indicating severely impaired cognition, and a Cognitive Loss/Dementia CAA dated 01/02/26 documented dementia and daily antipsychotic use. The care plan included an intervention for hospice to provide extra bathing on Mondays and Thursdays but lacked documentation of other hospice services. Physician orders dated 01/21/26 directed hospice of the family's choice to evaluate and treat, and the resident was observed seated in a Broda chair at the dining room table while a CNA attempted to assist with breakfast.

Administrative staff interviews revealed that the required Significant Change MDS was not completed at the time of the resident's admission to hospice. One administrative nurse stated she had completed a significant change MDS prior to the resident's hospice admission and acknowledged she should have completed another significant MDS after hospice admission. Another administrative nurse confirmed that the significant change MDS was not completed when the resident was admitted to hospice, clarifying that the earlier significant change MDS had been done for a prior significant change in health status. The facility's policy on Electronic Transmission of the MDS, effective 10/2025, stated that MDS assessments, including significant change assessments, would be transmitted per state and federal guidelines, but this was not followed for the hospice admission event.