Inaccurate MDS Assessment Related to PASRR Status
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for one resident who was admitted with a history of schizophrenia, depression, anxiety disorder, and persistent mood affective disorder. The resident's admission and annual MDS assessments both indicated that the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite documentation from the State of California showing that a Level II evaluation had been conducted and confirmed the presence of a serious mental illness requiring nursing facility services. The facility's policy required that all portions of the MDS be completed and certified for accuracy by the responsible staff, and that the information reflect the resident's status during the observation period. Interviews with facility staff, including the MDS Director and the Director of Nursing, confirmed that the MDS assessments for this resident were inaccurate regarding the resident's PASRR status. The care plan for the resident also noted impaired cognitive status and thought processes related to the resident's mental health diagnoses, which was inconsistent with the MDS documentation. The Executive Director acknowledged the expectation for MDS assessments to be accurate, but the deficiency was identified due to the failure to correctly document the resident's PASRR status on the MDS.