Failure to Complete and Accurately Document PASRR Screenings
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) Level 1 was fully and accurately completed for two residents, and did not complete a required PASRR Level 2 for one resident. For one resident with diagnoses including metabolic encephalopathy, alcohol-induced dementia, psychosis, and major depressive disorder, the PASRR Level 1 screening was found incomplete, missing pages 2 and 4, and there was no evidence of a Level 2 PASRR in the medical record despite the resident's significant mental health diagnoses and impaired cognitive function. The Director of Social Services acknowledged the incomplete documentation and the lack of a Level 2 PASRR, citing staffing issues and personal absence as reasons for the oversight. Another resident with a history of dementia, major depressive disorder, and schizophrenia had a PASRR Level 1 that indicated a Level 2 PASRR should have been requested due to a diagnosis of serious mental illness. The care plan and progress notes documented ongoing cognitive impairment, behavioral disturbances, and the use of antipsychotic and antidepressant medications. However, there was no evidence that a Level 2 PASRR was completed as required. The social worker admitted to being behind on PASRR documentation and stated that many residents were admitted without properly completed PASRR forms. A third resident with severe cognitive impairment and diagnoses including bipolar disorder, dementia, and anxiety had a PASRR Level 1 that was not accurately filled out, failing to indicate the resident's mental illness diagnosis and instead listing dementia as the primary diagnosis. The care plan reflected the resident's confusion and need for assistance with activities of daily living. The social worker again acknowledged the backlog and the need to review and correct PASRR documentation for residents who may require a Level 2 PASRR.