Failure to Update PASRR for Resident with Anxiety Disorder
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level I for a resident was accurately completed. The deficiency was identified when it was found that the PASRR Level I dated 09/15/2023 for a resident did not include an updated diagnosis of Anxiety Disorder, despite the resident having a medical diagnosis of Anxiety Disorder Unspecified. The resident was observed to be slightly anxious and was receiving Buspirone for anxiety, which was not reflected in the PASRR documentation. The PASRR Level I only identified Depressive Disorder and Insufficient Sleep Syndrome, and did not check the section for Serious Mental Illness (SMI). The Director of Nursing (DON) acknowledged that anxiolytic medications should prompt an update to the PASRR, but it was overlooked. The facility's policies and procedures require that all new admissions and readmissions are screened for mental disorders, intellectual disabilities, or related disorders per the Medicaid PASRR process. However, the oversight in updating the PASRR documentation led to the deficiency, as the resident's current mental health needs were not accurately reflected in the PASRR, which is crucial for determining the appropriate level of care and interventions needed.
Plan Of Correction
F645 PASARR Screening for MD & ID CFR(s): 483.20(k)(1)-(3) Plan for specific resident: On __, the level 1 PASARR for sampled resident #17 was updated to include the diagnosis of __. Method to assume compliance for other residents: On __, an in-service was provided to the psych nurse and social services by the DON on accurately updating PASARR. By __, the psych nurse will have conducted audits of medical records of residents to ensure that PASARR has been accurately updated. This will be done to ensure 100% compliance. System: As of __, the psych nurse will conduct on a weekly basis for a period of 3 months 5 random level 1 PASARR to ensure they have been accurately updated. As of __, the DON will provide additional in-service as needed based on findings. The threshold for compliance is 100%. Monitoring: As of __, the quality assurance and performance improvement coordinator will use a monitoring tool to check on a weekly basis for a period of 3 months 5 random level 1 PASARR to ensure that they have been updated. This will be done to ensure 100%.