Failure to Incorporate PASARR Recommendations into Care Plan
Penalty
Summary
The facility failed to incorporate the recommendations from a Level II Preadmission Screening and Resident Review (PASARR) evaluation into the care plan for a resident with a history of bipolar disorder, anxiety, and PTSD. The resident was found to be cognitively intact and had qualified for a Level II PASARR due to serious mental health conditions. The Level II psychiatric evaluation included specific recommendations for environmental safety, staff approaches (such as assigning female staff for intimate care due to past trauma with males), and behavioral interventions involving close coordination with the social services department. Despite these recommendations, a review of the resident's care plan showed no evidence that the PASARR findings or suggested interventions were incorporated. Interviews with facility staff, including social services and clinical leadership, revealed a lack of awareness regarding the recommendations and an absence of updates to the care plan. The facility's policy required that PASARR recommendations be included in the person-centered care plan, but this was not followed for the resident in question.