Incomplete PASARR and Medical Record Documentation
Penalty
Summary
Facility staff failed to ensure that resident medical records were complete and accurate, and that records were properly maintained, as evidenced by several deficiencies in the handling of Preadmission Screening and Resident Review (PASARR) documentation and wound care records. For three residents reviewed for PASARR, there were incomplete or missing sections in the required forms. In one case, a PASARR form had an entire section left blank despite instructions to complete it if certain criteria were met. Another resident's PASARR form was missing a required section, and staff acknowledged that the form should have been completed in its entirety. For a third resident, documentation indicated a need for a Level II screening, but the facility did not have the necessary follow-up documentation on file, despite staff expectations that such records should be maintained. Additionally, for one resident reviewed during the annual survey, the facility failed to maintain complete skin and wound documentation following the resident's discharge to a hospital. The medical record lacked any skin and wound documentation after a specific date, and the facility was unable to provide information about the hospital to which the resident was sent. These findings demonstrate lapses in the facility's processes for maintaining accurate and complete medical records in accordance with professional standards.