Failure to Address PASRR Level II Outcome in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed all of a resident's needs, specifically omitting the required PASRR Level II outcome for a resident with serious mental illness. According to the facility's policy, the interdisciplinary team is responsible for creating a person-centered care plan that includes measurable objectives, timeframes, and addresses specialized services as recommended by PASRR. However, review of the medical record showed that the resident, who was admitted with diagnoses of Bipolar Disorder and Major Depressive Disorder and had a PASRR Level II outcome, did not have this outcome reflected in their care plan as of the most recent revision. During interviews, both the RN MDS Coordinator and the DON confirmed that the PASRR Level II outcome was not included in the resident's care plan, despite facility expectations and policy requirements. The omission was identified through policy review, medical record review, and staff interviews, confirming that the care plan did not comprehensively address the resident's mental health needs as required.