Failure to Complete Significant Change MDS After Fall With Major Fractures
Penalty
Summary
The deficiency involves the facility’s failure to complete a Significant Change in Status MDS assessment following a resident’s major decline in condition after a fall with serious injury. The resident had a history of multiple vertebral compression fractures, bone density disorders, and a displaced condyle fracture of the femur. The record shows the resident experienced a witnessed fall and subsequently complained of pain in the lower back, right leg and hip, and left arm. The practitioner was notified and ordered topical pain medication, oxycodone, labs, and x‑rays. A physical therapy note documented that, a few days after the fall, the resident reported severe back pain rated 10/10 and ongoing head pain, and stated that a higher level of care was required due to decline in function, mobility, and independence. Further record review showed that an x‑ray follow‑up was positive for a right femur fracture, and the resident was sent to the emergency department. The resident was later readmitted after hospitalization, where she underwent ORIF for the right femoral fracture and was discharged back with a knee immobilizer and additional findings of lumbar spine compression fractures and bruising to the upper extremities. Despite these significant injuries, surgical intervention, and documented decline in functional status, the facility did not complete a Significant Change MDS until approximately one and a half months after the injury. In an interview, the DON confirmed that a Change in Condition MDS was not completed following discovery of the major injuries and acknowledged that it was her expectation that such an assessment should have been completed and submitted within 14 days.
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