Inaccurate MDS Assessments of PASRR Status
Penalty
Summary
The facility failed to ensure that the comprehensive assessments for a resident accurately reflected the individual's Pre-admission Screening and Resident Review (PASRR) status. Record review showed that the annual Minimum Data Set (MDS) assessments for the current and previous year did not indicate that the resident was considered by the state as PASRR Level II, despite the care plan identifying the resident as such. Both MDS assessments listed the resident as not having serious mental illness and/or intellectual disability or a related condition according to the state Level II PASRR process, which was inconsistent with the care plan and the resident's actual PASRR status. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the comprehensive MDS assessments for both years were inaccurate and did not reflect the resident's PASRR Level II status, which had been determined by the state. The resident in question was cognitively intact and had active diagnoses including psychotic disorder, anxiety, and depression. The deficiency was identified through review of records and staff interviews, which established that the assessments did not accurately represent the resident's PASRR status.