Inaccurate MDS Assessments and PASRR Identification
Penalty
Summary
The facility failed to ensure accurate completion and submission of Minimum Data Set (MDS) assessments for multiple residents. In one instance, a resident's MDS indicated discharge to a short-term general hospital, while progress notes documented that the resident was actually discharged home with family, resulting in conflicting records. Additionally, for several residents with documented diagnoses of anxiety, major depression, schizophrenia, and bipolar disorder, the MDS assessments did not accurately reflect their mental health status in Section A1500, which is used for PASRR (Preadmission Screening and Resident Review) identification. Specifically, the assessments indicated that these residents were not considered by the state Level II PASRR process to have serious mental illness or intellectual/developmental disabilities, despite their diagnoses. These inaccuracies were identified through interviews and review of medical records, affecting all five residents reviewed for assessment accuracy. The facility's own PASRR review policy requires identification and evaluation of all residents for serious mental illness or intellectual/developmental disabilities to ensure appropriate placement and services, but the assessments failed to meet these requirements. The deficiencies were limited to the documentation and coding of resident assessments and did not include any mention of corrective or follow-up actions.