Inaccurate PASARR Screenings for Residents
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level I was completed accurately prior to admission for three residents. The PASARR Level I screenings for these residents were either incomplete or incorrect, failing to reflect the residents' current diagnoses and medication needs. This deficiency was identified during a survey, which included observations, record reviews, and interviews with facility staff. Resident #50 was admitted with certain diagnoses, but the PASARR Level I did not include these diagnoses, and no PASARR Level II was deemed necessary. The Minimum Data Set (MDS) assessment indicated severe mental status issues, yet the PASARR did not reflect this, leading to a discrepancy in the resident's care needs. Interviews with the Admissions Director and Director of Nursing (DON) confirmed that the PASARR was incorrect and should have included the relevant diagnoses. Similarly, Resident #83's PASARR Level I was completed without acknowledging the resident's acute failure and affective disorder diagnoses. The MDS assessment showed severe mental status issues, but the PASARR did not require a Level II review. The DON acknowledged the oversight, stating that the PASARR should have included the diagnoses. Resident #60 also had an incomplete PASARR, which did not reflect the resident's known condition and aggressive behaviors. The DON admitted that the PASARR should have been updated to reflect the resident's current mental illness diagnoses and medication needs.
Plan Of Correction
PASARR screening for MD and ID Identify patients that were at risk and what did: Patients #50, 83 & 60 were reassessed in the PASSAR. Resident #50 was discharged on home with Daughter. Patients #83 and #60 remain in the facility. PASARS were reevaluated to reflect proper diagnosis, and PASARR resident review screening was requested. This was completed on for resident #83. Ref #60 the resident review was completed on. A full house audit was completed identified the issues, all residents PASSARS were reviewed for accuracy. How will you identify other patents that are at risk: On a QAPI Meeting occurred to review the PASSAR and provided education to the committee. A full house audit was completed identified the issues, all residents PASSARS were reviewed for accuracy. The consistency of the audit was to make the PASSARES Level 1 and 2 are accurate and in place. Any updates were made and being made during the course of the audit. Measures put in Place: The facility admissions team will work with local hospitals to ensure prior to admission, that the screening uses the PASSAR criteria. Admissions Director and Director of Nursing as well Social Service were provided the PASSAR education on. The Director of Nursing and admissions will review all new admissions during the week, to ensure accuracy during morning meeting and on weekend a nursing supervisor will review for accuracy and compliance, and if patient was readmitted to compare with prior PASSAR to ensure if any new changes have occurred. Additionally, the Social Service Department and Nursing will also address when Physician changes orders for medications, then the PASSAR will be reviewed and updated if necessary. The MDS Department will also be part of reevaluating during the quarterly assessments. Additionally, as of a QAPI tool was developed as part of Pre-Admission Screening & Resident Review (PASARR) Audit was implemented and will be done upon admission and Gang Tackling, which is the facilities continuous quality improvement program Monthly Review. How will you monitor: The Administrator/ Nursing Management team and or Designee will review all admissions for compliance and keep a running list for QAPI. Pre-Admission Screening & Resident Review (PASSAR) Audit will be done upon admission and Gang Tackling Monthly Review. The Admissions Director and Director of Nursing and or designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.