Inaccurate MDS Assessments Related to PASRR Documentation
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, as determined through record review and staff interviews. For one resident with chronic respiratory failure, anxiety, panic disorder, and depression, both PASRR Level I and II assessments documented serious mental illness, but the Annual MDS assessment incorrectly indicated that the resident was not considered to have a serious mental illness or intellectual disability. The MDS nurse acknowledged the assessment was inaccurate after reviewing the documentation. Another resident with spastic quadriplegic cerebral palsy, chronic respiratory failure, and epilepsy had a PASRR Level I indicating an intellectual disability, but the Admissions MDS assessment incorrectly answered 'no' to the presence of a serious mental illness or intellectual disability. Similarly, a third resident with quadriplegia, depression, and anxiety had a PASRR Level II documenting severe mental illness, but the comprehensive MDS assessment did not reflect this. In each case, the MDS nurse confirmed the assessments were completed inaccurately due to misunderstanding of PASRR documentation requirements.