Failure to Complete Accurate PASARR Screening for Resident with Intellectual Disabilities
Penalty
Summary
The facility failed to accurately complete the Pre-admission Screening and Resident Review (PASARR) process for one resident who was admitted with a diagnosis of unspecified intellectual disabilities. The PASARR Level I screening form did not indicate the resident's intellectual disability, despite the electronic medical record and family member confirming the diagnosis had been present for the resident's entire life. The resident's admission Minimum Data Set (MDS) also showed moderate cognitive impairment, but the care plan did not reflect the intellectual disability diagnosis or any specialized services provided. Interviews with the Social Services Director (SSD) revealed that a Level II PASARR referral was not made, as the SSD was unable to locate a current diagnosis of intellectual disability at the time of admission. The SSD also confirmed that the facility did not have a PASARR policy and relied on federal requirements. The failure to identify and document the intellectual disability resulted in the resident not being evaluated for or provided with specialized care and treatment as required.