Failure to Incorporate PASRR II Recommendations into Care Plan
Penalty
Summary
The facility failed to ensure that a resident's PASRR II (Pre-admission Screening and Resident Review) recommendations were incorporated into the care plan. The resident, who was admitted with a history of stroke, mental health disorders, suicidal ideations, and aggressive behavior, had a PASRR II evaluation completed that included specific recommendations such as providing environmental and social structuring, memory cues, art supplies, increased access to books, and the contact information for a Crisis Team. However, the care plan was not updated to reflect these recommendations, and staff did not implement the suggested interventions. Observations revealed that the resident's room lacked books, art supplies, and photos of loved ones, and the resident confirmed not having access to these items. Interviews with staff indicated a lack of clarity and follow-through regarding the handling and implementation of the PASRR II recommendations. The social services staff could not recall what was done with the recommendations, and the resident care manager did not see the PASRR II after its completion. The regional nurse confirmed that staff were expected to review and implement PASRR II recommendations, but this was not done for the resident in question.