Failure to Timely Update PASRR Assessments After Significant Change in Condition
Penalty
Summary
The facility failed to ensure timely completion and notification of Preadmission Screening and Resident Review (PASRR) assessments following significant changes in condition for two residents with mental health diagnoses. For one resident with PTSD, the clinical record showed a new onset of hallucinations and delusions documented in multiple Minimum Data Set (MDS) assessments and care area assessments. However, the PASRR documentation did not reflect these new symptoms, and the Level II PASRR referral was made only for a new anti-depressant order, without addressing the delusions or hallucinations. For another resident with depression and dementia, the clinical record and care plan documented the onset of vivid hallucinations and delusions, but there was no evidence of a significant change PASRR referral when these symptoms began. Interviews with facility staff revealed a lack of awareness regarding the requirement to notify the PASRR evaluator about significant changes involving delusions or hallucinations. The Director of Nursing Services stated that PASRR information should be updated and communicated to the care plan, while the Social Services Director was unaware that symptoms beyond depression or anxiety required PASRR notification. The facility's policy required PASRR reviews and updates with significant changes in residents' physical or mental condition, but this was not followed for the two residents in question.