Failure to Complete Accurate PASRR Screenings Prior to Admission
Penalty
Summary
The facility failed to ensure that Level I Preadmission Screening and Resident Review (PASRR) assessments were accurately completed prior to admission and appropriately revised following admission for three residents with serious mental illness (SMI) or intellectual disability (ID) or related conditions. For these residents, medical records indicated diagnoses such as unspecified depressive disorder, major depressive disorder, and generalized anxiety disorder, as well as the use of psychotropic medications. However, the PASRR Level I screenings did not reflect these diagnoses, and in some cases, no diagnoses were checked or identified, despite clear documentation in the medical records and care plans. For one resident, the PASRR Level I completed by a hospital social worker did not indicate any mental illness or ID, even though the resident's medical record and care plan documented diagnoses and ongoing use of psychotropic medications. Another resident's PASRR Level I similarly failed to identify SMI, despite the presence of relevant diagnoses and medication orders. In the third case, the PASRR Level I did not check for SMI, and the screening was not updated to reflect the resident's current condition, even though the care plan and psychiatric consultation documented a history of major depressive disorder and generalized anxiety disorder. Interviews with facility staff revealed that the Social Services Director (SSD) was responsible for completing the Level I PASRR assessments, but the SSD stated she did not have the required license to complete these assessments. The Director of Nursing (DON) indicated that she would complete the assessments if the SSD did not. The facility's policy required that all residents have a PASRR Level I completed prior to admission and that the screening reflect the resident's current condition and diagnosis, but this was not followed for the residents in question.
Plan Of Correction
F 645 1. Residents #8, 12, 13 PASRR were immediately updated on after finding out that there was some missing information on them. 2. An audit on all current residents to ensure that their PASRR were completed accurately was conducted. 3. Regulations and criteria for completing PASRR were reviewed. 4. Admission personnel was instructed to ensure that PASRR comes in completed with every new admission. 5. Social Service with MDS Coordination will review all PASRR within 72 hours of admission for accuracy to alert D.O.N if there is any discrepancy. 6. If found incorrectly completed, the D.O.N will do the PASRR over and social worker will upload updated PASRR into the resident's record. 7. D.O.N or designee will do random checks monthly on all new admission PASRR to ensure compliance for the next 3 months. Good day. Review of the medical records for Resident #13 revealed the resident was admitted to the facility on. Clinical diagnoses included but were not limited to: Unspecified unspecified severity, without behavioral disturbance, disturbance, disturbance, Major recurrent unspecified. Unspecified is not due to a substance or known physiological condition. Review of the Physician's Orders Sheet for Resident #13 revealed, Resident #13 had orders that included but not limited to: Oral Tablet 25 Milligram (MG) - Give one (1) tablet by one time a day for Unspecified; Oral Tablet 5 MG - Give 1 tablet by one time a day for; oral tablet 50 MG - give 1 tablet by at bedtime for; unspecified; Oral Tablet 7.5 MG - Give 1 tablet by at bedtime for. Record Review of Resident #13's Level | PASRR (Preadmission Screening and Resident Review) documented Section 1: PASARR Screen Decision Making: A: Mental Illness( ) or suspected (check all that apply) - No diagnoses checked off. Findings based on documented history were-Section II Other indicators for PASRR screening Decision-Making: All checked-no. Does individuals have validating documentation to support or related - no. Section III Not a provisional admission. Section No diagnosis or suspicion of Serious Mental Illness (SMI) or intellectual. Findings will be brought to the monthly QA meetings until such time as substantial compliance has been determined, to ensure compliance has been achieved.