Failure to Initiate Timely PASSAR Follow-Up for Resident
Penalty
Summary
The facility failed to initiate a change in condition/PASSAR follow-up for a resident who was admitted with diagnoses including diabetes, stroke, and mental illness. The resident had impaired cognition and required extensive assistance with activities of daily living. Upon admission, a hospital exemption discharge was noted, and a tentative discharge date was scheduled within two weeks. However, the resident remained in the facility beyond the 30-day exemption period without a Level II OBRA assessment being initiated, as required if the resident's stay extended beyond 30 days. The deficiency was identified during a record review and interviews with facility staff. The Social Worker Designee and the Director of Nursing were unable to provide additional documentation regarding the resident's PASSAR correspondence. It was later revealed that a new PASSAR correspondence was documented, indicating a change in condition, but this was not completed in a timely manner. The facility's policy requires that a change in condition be submitted to the local community mental health program for review if a resident remains in the facility longer than the initial 30-day exemption period.
Plan Of Correction
1. Res. #3 had a change in condition triggered at survey by the Social Services Designee, and CMH has begun the Level 2 screening. 2. Social Service Designee reviewed all residents in building to ensure that no other residents had missed change in condition. 3. Social Service Designee and Admission Director were in-serviced on Pre-Admission Screening and Guest/Resident Review Policy and Procedure. 4. Social Service Designee will audit 25% of resident population weekly x4, then monthly x2 to ensure that all PASSARs are current and up to date. Any concerns will be addressed. Results of audit will be reported to QA Monthly. Social Service Designee will be in charge of sustained compliance.