Inaccurate MDS Assessments Related to PASRR Status
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, resulting in incorrect documentation regarding their mental health status and PASRR (Preadmission Screening and Resident Review) determinations. One resident, with diagnoses including Wernicke's encephalopathy, cognitive communication deficit, delusional disorder, and alcohol-induced dementia, had an annual MDS assessment that did not reflect updated mental health diagnoses. The assessment incorrectly indicated that the resident was not considered by the state Level II PASRR process to have a serious mental illness, despite documentation of an active psychotic disorder diagnosis. The MDS Coordinator confirmed that the PASRR Level I and II had not been updated following the new diagnoses. Another resident, admitted and readmitted with diagnoses such as PTSD, major depressive disorder, and anxiety, also had an annual MDS assessment that inaccurately documented the absence of a PASRR Level II determination. However, a PASRR Level II was present in the resident's electronic medical record. The MDS Coordinator acknowledged that the assessment should have indicated the presence of a PASRR Level II. These inaccuracies were identified through record review and staff interviews, demonstrating a failure to ensure that MDS assessments included correct and current information for residents with serious mental illness or related conditions.