Nursing homes and other healthcare facilities are required to assess residents who experience a significant change in status using the CMS-specified Resident Assessment Instrument (RAI). A significant change is defined as a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both. Examples of a significant change include changes in decision-making ability, emergence of a new pressure ulcer, or changes in incontinence patterns. The RAI must be completed within 14 days after the determination that a significant change has occurred. In addition, the facility must document in the medical record when the determination is made that the resident meets the criteria for a Significant Change in Status Assessment. This new requirement will help ensure that residents receive the care they need in a timely manner, and will help nursing homes and other healthcare facilities to proactively identify and prevent deficiencies.

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