Failure to Maintain Complete PASRR Documentation in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not ensuring that the resident's preadmission PASRR Level 1 screening and subsequent evaluations were included in the medical record. Specifically, a review of the resident's electronic medical record revealed that the PASRR Level 1 screening was not uploaded, despite the resident having multiple complex diagnoses, including end stage renal disease, chronic respiratory failure with hypoxia, Type 2 Diabetes, dysphagia, and chronic diastolic heart failure. The absence of the PASRR documentation was confirmed during an interview with the MDS Coordinator, who stated that it was the responsibility of the MDS office to upload the PASRR Level 1 screening into the resident's medical record during admission, using the Simple software system. Further review with the MDS Coordinator confirmed that the PASRR Level 1 screening had been completed and was available in the Simple system, and that a PASRR Level II evaluation had also been completed. However, neither document had been uploaded to the resident's medical record as required by facility policy, which states that all assessments and services must be documented in the resident's medical record in accordance with state law and facility policy, and completed at the time of service or no later than the shift in which the service occurred.