| 6133 |
ROLLING GREEN VILLAGE |
425160 |
1 HOKE SMITH BOULEVARD |
GREENVILLE |
SC |
29615 |
2014-12-31 |
274 |
D |
0 |
1 |
D2FB11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual the facility failed to conduct a Significant Change in Status Assessment (SCSA) following a decline in function for Residents #2 and #7, 2 of 4 residents reviewed with significant changes. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. On 12/31/14 at 3:43 PM, comparison of the Annual Minimal Data Set ((MDS) dated [DATE] to the quarterly assessment dated [DATE] revealed a decline in 5 areas of Activities of Daily Living (ADLs). The resident received limited assistance with bed mobility, transfers dressing, toileting, and supervision with hygiene on the 5/27/14 annual assessment and was newly coded as requiring extensive assistance in all 5 of the areas on the 8/26/14 assessment. In addition, review of the quarterly assessment dated [DATE] revealed the resident was coded as 8, activity did not occur, during the 7 days ending 11/25/14 for ambulation, locomotion, dressing, eating, hygiene and bathing. During an interview on 12/31/14 at 5:15, MDS Coordinators #1 and #2 confirmed the areas of decline and confirmed that a SCSA should have been completed. MDS Coordinator #2 stated that Section G, Activities of Daily Living, had not been completed on the 11/25/14 assessment before it was locked and transmitted. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. On 12/31/14 at 11:15 AM, comparison of the 2/24/14 Admission to the 11/25/14 Quarterly MDS revealed a decline in locomotion and in bowel and bladder incontinence. Further review of the 8/26/14 and 5/27/14 Quarterly assessments was conducted to determine when the declines had occurred. Review of the 5/27/14 MDS revealed Resident #7 had improved in ambulation and locomotion since the admission assessment and was newly coded as limited assistance. Comparison of the 8/26/14 Quarterly MDS to the 11/25/14 Quarterly assessment revealed Resident #7 had declined in ambulation and hygiene and was newly coded as requiring extensive assistance. Further review revealed the resident also had a change in bladder continence from occasionally to frequently incontinent and from continent to occasionally incontinent of bowel. During an interview on 12/1/14 at 4:45 PM, the Director of Nursing confirmed the 3 areas of decline from 8/26/14 to 11/25/14 and that a SCSA should have been completed. At 5:15 PM, MDS Coordinators #1 and #2 stated that Resident #7 had an acute episode of Pneumonia in November and that was why a SCSA had not been done. The MDS Coordinators provided documentation of the resident's current continence status indicating the resident was again continent of bowel and bladder. The MDS Coordinators also confirmed the documented decline in ambulation and hygiene and stated they would have to review the ADL documentation for that time period to confirm the information. No further information or documentation was provided at the time of exit. There was no documentation in the record to indicate that the facility had monitored the resident's function for return to baseline. A review of the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, Chapter 2, page 2-20 revealed The SCSA (Significant Change in Status Assessment) is a comprehensive assessment for a resident that must be completed when the IDT (Interdisciplinary Team) has determined that a resident meets the significant change guidelines for either improvement or decline. The manual further stated A SCSA is appropriate when: There is a determination that a significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments . The Guidelines for Determining a Significant Change in a Resident's Status further state A SCSA is also appropriate if there is a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of ADL decline or improvement). Listed in the areas of decline was Any decline in an ADL physical functioning area where a resident is newly coded as Extensive assistance, Total dependence, or Activity did not occur since last assessment. In addition, the manual stated MDS assessments are not required for minor or temporary variations in resident status - in these cases, the resident's condition is expected to return to baseline within 2 weeks. However, staff must note these transient changes in the resident's status in the resident's record and implement necessary assessment, care planning, and clinical interventions, even though an MDS assessment is not required. The RAI manual also stated If the condition has not resolved within 2 weeks, staff should begin a SCSA and that This situation should be documented in the resident's clinical record along with the plan for subsequent monitoring and, if the problem persists or worsens, a SCSA may be warranted. |
2018-05-01 |