Failure to Incorporate PASRR Recommendations into Care Plan
Penalty
Summary
The facility failed to incorporate the recommendations from a Level II Preadmission Screening and Resident Review (PASRR) into the assessment and care planning for a resident with a history of depression and moderate dementia with anxiety. The PASRR, completed for the resident, included specific recommendations regarding environment, staff approach and training, behavioral support, and activity engagement, such as encouraging daily activities for structure and mental stimulation, and consulting the resident's family about preferred activities. The PASRR also detailed the need for a consistent routine, consistent staff, gentle communication, and monitoring if a roommate was unavoidable due to the resident's mental health history and behavioral triggers. Despite these recommendations, review of the resident's care plan showed that none of the PASRR recommendations were included. Multiple observations over several days revealed the resident was often in their room without activity items, and staff interviews confirmed that PASRR recommendations were not being added to care plans. The Social Services Director stated they were unaware that PASRR recommendations needed to be incorporated into the care plan, and the process had only involved scanning the PASRR evaluation into the medical record.