Failure to Update PASRR Following Resident Behavioral Changes
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) for a resident was updated to accurately reflect changes in the resident's condition. The resident, who had a history of alcoholic cirrhosis, major depressive disorder, insomnia, and a prior myocardial infarction, experienced several behavioral incidents, including altercations with other residents, verbal aggression, and suspected alcohol intoxication. Despite these significant changes and ongoing behavioral health concerns, the PASRR was not revised to include substance-related disorders or issues with interpersonal behaviors, and it continued to list a discontinued medication as active. Documentation showed that the resident had multiple behavioral incidents over several months, including altercations, irritability, and verbal aggression. Progress notes and care plans indicated interventions for ineffective coping related to alcohol abuse and referrals for mental health support. However, the facility's interdisciplinary team did not review or update the PASRR recommendations in response to these changes, and the most recent PASRR on file was outdated and inaccurate. Interviews with staff, including the admissions director and DON, confirmed that the PASRR was not current and did not reflect the resident's present status or needs. Facility policies required the IDT to review PASRR recommendations and to update documentation following significant changes in a resident's condition, but there was no evidence that these procedures were followed in this case.