Published Jan 20, 2017
Melissamds17
9 Posts
I have a resident recently readmitted from hospital with new diagnosis of Acute Leukemia. Resident has unintentional weight loss related to leukemia, chemo as evidenced by & weight loss x3 weeks.
I was on PTOs and another MDS opened an annual assessment. My question is do we need to open a significant change instead of an annual? I am working right know on CAAs, and I am just afraid that I missed a significant change assessment.
tomorrow I have to close and submit my assessment, please any advice would help thanks.
Talino
1,010 Posts
Do the SCSA.
If a significant change in status is identified in the process of completing any OBRA assessment except Admission and SCSAs, code and complete the assessment as a comprehensive SCSA instead
Thank you Talino
I have another pt with annual assessment ARD 01/16/17 and Per Weight Change Note dated 01/11/17
Pt loss (22%)X30day. Per Weight Change Note dated 01/20/17, Pt gained (5.8%)x1week. In this case where I have only one area of change I am hesitating to opened a significant assessment.
I can understand your hesitation - whether to just do the SCSA now rather than wait and be compelled to do the SCSA down the road.
That's a huge weight loss in 30 days. When the change is unclear whether it satifies the SCSA guideline, we have up to 14 days to determine if the criteria is met. To be safe, try to document the reason for the loss which "may be self-limiting" that will resolve with the current clinical intervention. 'looks like you are already seeing an improvement.
RAI, bullet 2, p2-25
If there is only one change, staff may still decide that the resident would benefit from a SCSA. It is important to remember that each resident's situation is unique and the IDT must make the decision as to whether or not the resident will benefit from a SCSA. Nursing homes must document a rationale, in the resident's medical record, forcompleting a SCSA that does not meet the criteria for completion.
You should be fine either way.
Thank you Talino for your support, I really appreciate it.