In Focus: Recognizing Significant Change

Taking a team approach to identifying major changes in resident health status will result in better care and may avoid a common survey citation.

Jane Belt, RN 5/1/2018

Caregiving

Not much has changed about the Minimum Data Set (MDS) significant change in status assessments (SCSAs) over the past 20 years. Nonetheless, in the long term care survey process (LTCSP) that took effect Nov. 28, 2017, F637 (Comprehensive Assessment After Significant Change) is still being cited, causing angst during surveys. Here are some best practices to smooth out the SCSA process in order to reduce or eliminate this citation.

Specifics of Recent Citations

Review the February 2018 Text of Deficiencies for instructive examples of recent survey citations. The reasons given by interviewed staff members for not completing an SCSA consistently reveal a lack of communication (such as, “No one told me about the weight loss” or “There was no process to track changes”). Examples include:

An admission assessment was completed on 11/22/17. The resident elected hospice on 11/30/17, and no significant change MDS was completed.
Failed to complete an SCSA when two or more areas of change in the resident’s status were noted on the MDS. The nurse interviewed noted she had no process for identifying when an SCSA would be required.
Failed to complete the significant change MDS when reviewing a resident who returned from the hospital. The surveyor reviewed nursing notes for a period of 20 days and found that the resident had declined in ambulation, eating, and was using oxygen. Staff said they were trying to determine if the resident would bounce back. Staff agreed that the 14-day review should have started when the resident returned from the hospital.
Staff failed to complete the SCSA in a timely manner for one resident (decline in range of motion and weight loss), and another resident elected hospice and did not have the assessment completed.

Avoid Other Deficiencies

Even though the citations were minor in nature (with a severity level/scope of D), the lack of assessment that led to the failure to conduct an SCSA is extremely concerning. The CMS LTCSP Mapping Document (a resource available to the survey team) identifies the care area questions that will trigger critical element pathways or investigation tasks during the new standard process with the associated F-tags.

For example, it shows how failing to complete a significant change assessment can lead to multiple other deficiencies, such as care planning, accident hazards, unnecessary medications, activities, quality of care, and unmet activities of daily living (ADL) needs. These types of deficiencies can of course lead to greater severity, due to the possibility of harm or even jeopardy.

Learn the Definitions

The definition of a significant change—from page 2-22 of the Resident Assessment Instrument (RAI) User’s Manual—should be well known by nursing staff and interdisciplinary team (IDT) members:

A “significant change” is a major decline or improvement in a resident’s status that:

Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions and the decline is not considered self-limiting;
Impacts more than one area of the resident’s health status; and
Requires interdisciplinary review and/or revision of the care plan.

Self-limiting is when the condition will normally resolve itself without further intervention or with standard disease-related clinical interventions. For example, a resident with an upper respiratory condition might receive acetaminophen and/or cough lozenges to decrease discomfort. The RAI manual’s definition goes on to say, however, that if the condition has not resolved within two weeks, staff should begin an SCSA.

Know the Time Frame for Completion

The completion time frame for the significant change MDS is clearly specified as 14 days, or two weeks. The regulations allow the IDT 14 days to determine whether the resident meets the significant change guidelines and state that documentation must be in place in the medical record to note the timing of the significant change identification.

Putting that into context with the completion requirements for an SCSA, the IDT has 14 days to determine whether there has been a significant change, and then the MDS and Care Area Assessments (CAAs) must be completed within 14 days of the determination (the assessment reference date [ARD] plus 14 calendar days). In other words, the IDT does have time to get this extra assessment completed.

Understand the Regulations

The SCSA is a comprehensive assessment, and that means completion of the CAAs, but is the team remembering the guidance on page 2-24? The RAI User’s Manual states that all triggered CAAs must be reviewed and compared with the resident’s previous status, and if there was no change in a care area, the prior documentation for that area may be carried forward. That information location must simply be documented in the medical record.

The manual also provides some flexibility for completing an admission assessment if a resident elects or revokes the hospice benefit prior to the ARD of the admission MDS or after that ARD as long as the assessment has not been completed. In those cases, the ARD can be adjusted to the date of election or revocation so that only the admission assessment is required (pages 2-23 and 2-24).

An SCSA would not be appropriate if a resident has stabilized and discharge is expected in the immediate future. The IDT needs to spend its time on the discharge plan—not on an SCSA.

Become Familiar With What Prompts an SCSA

The circumstances that require the nursing facility staff to complete a significant change assessment are stated on page 2-23:

Determination that a significant change in a resident’s condition from his or her baseline has occurred by comparison of the resident’s current status to the most recent Omnibus Budget Reconciliation Act of 1987 (OBRA 87) assessment;
Condition is not expected to return to baseline within two weeks;
Resident enrolls in a hospice program;
Resident receiving hospice services decides to discontinue services (revokes hospice); or
Resident changes hospice providers.

Comparing assessments is probably one of the most important actions staff members can take. The subtle changes in a resident’s condition are easily identified when time is taken to compare the current assessment with the prior OBRA 87 assessment. Each discipline can do this and report to the MDS nurse so that the change does not go unnoticed.

Additionally, many MDS software programs have an edit built in that warns the assessor when it appears the resident has experienced a significant change—a warning that should not be taken lightly. All IDT members should look, compare, and discuss so that the determination of a significant change can be a team decision.

Other signs also help determine whether an SCSA must be completed:

A decline or improvement in more than one area of the resident’s health status; or
A change in more than one area within the same domain, such as the ADLs.

The guidelines listed in the RAI manual on pages 2-24 through 2-26 are merely guidelines; the list is not exhaustive.

Seek Significance

As each member of the IDT completes a section of the MDS and observes a change, he or she should ask the question: Is this significant? Each team member must be accountable for noting whether that part of the MDS constitutes one or two areas of a major decline or improvement in the resident’s health status.

If it is, the MDS nurse must be confident that the staff member answered the question: Is this significant? It is not one person’s responsibility to identify significant change—it is the team’s responsibility.

Jane Belt, RN, MS, RAC-MT, RAC-CT, QCP, is curriculum development specialist at the American Association of Nurse Assessment Coordination. She can be reached at jbelt@aanac.org.