Failure to Incorporate PASRR Level II Recommendations for Visually Impaired Resident
Penalty
Summary
A deficiency was identified when the facility failed to incorporate the recommendations from a PASRR level II determination into the care plan of a resident with visual impairment. The PASRR level II, completed after a level I referral, specified that the resident required services and accommodations for visual impairment, including support with activities of daily living, nursing care, activities, care plan conferences, and assistance with reviewing or signing medical or financial documents. However, the resident's care plan, last revised prior to the PASRR determination, only referenced general vision care approaches and did not reflect the specific PASRR recommendations. Record review showed that the resident had a history of impaired vision related to diabetes and dense cataracts, had declined cataract surgery, and had periodic eye consultations. During interviews, facility staff were unable to provide documentation that the PASRR level II recommendations had been incorporated into the care plan. The PASRR determination was not readily accessible in the electronic medical record, and staff only obtained it upon the surveyor's request. The deficiency was confirmed through record review and staff interviews.