Failure to Complete and Update PASRR Assessments as Required
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were accurately completed prior to or upon admission, or updated when residents' conditions changed, for four out of five residents reviewed. Specifically, two residents were admitted without a Level I PASRR completed preadmission, with the assessments being performed only after admission. Another resident's PASRR did not accurately reflect all relevant diagnoses, such as psychotic or delusional disorders, and was not revised upon admission. Additionally, a resident who began experiencing hallucinations and delusions did not have their PASRR updated to reflect these significant changes in condition. Record reviews and staff interviews revealed that the social worker responsible for PASRR completion and accuracy was uncertain about the process and acknowledged errors in the documentation. One resident's PASRR indicated depression but did not trigger a required Level II evaluation, contrary to PASRR instructions. The administrator confirmed awareness of the requirement for preadmission Level I PASRRs but was unsure why they were not completed as required. These deficiencies were identified through observation, interview, and record review, and were in violation of the facility's own policy and state regulations.