Failure to Incorporate PASRR Recommendations into Care Planning
Penalty
Summary
The facility failed to incorporate recommendations from the Pre-admission Screening and Resident Review (PASRR) Level II evaluation into the Minimum Data Set (MDS) assessment and care planning for one resident. Record review showed that the PASRR Level I and Level II evaluations documented a diagnosis of schizophrenia as a major mental illness (MMI) for the resident, but this diagnosis was not reflected in the resident's medical record, MDS assessments, or care plan. The facility's PASRR policy requires that recommendations from PASRR Level II determinations be included in the person-centered care plan and during transitions of care. Staff interview with the Director of Nursing (DON) confirmed that the PASRR Level I and II findings should have been identified and addressed, and that updated PASRR evaluations should have been requested. The failure to document and incorporate the resident's mental health diagnosis as identified by PASRR evaluations resulted in the resident's specialized mental health needs not being included in their care planning.