Inaccurate MDS Documentation of PASRR Level II Determinations
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of five residents, specifically in relation to their Preadmission Screening and Resident Review (PASRR) Level II evaluations and determinations of serious mental illness. For each of these residents, documentation showed that they had been evaluated by a mental health authority and determined to have serious mental illnesses such as bipolar disorder, depression, anxiety, or PTSD. However, the corresponding MDS assessments did not indicate in section A1500 that these residents had been evaluated by PASRR Level II and determined to have a serious mental illness, despite clear evidence in their records and PASRR documentation. This deficiency was identified through record review and staff interviews, where the MDS Coordinator, along with the Social Services Director (SSD) and Director of Nursing (DON), confirmed that the MDS assessments for these residents should have been marked to reflect the PASRR Level II evaluations. The residents involved had complex medical and psychiatric histories, including conditions such as congestive heart failure, Guillain-Barre Syndrome, esophageal obstruction, and various mental health disorders. The failure to accurately document PASRR Level II determinations in the MDS assessments was consistent across multiple assessment dates for several residents.