Failure to Develop Comprehensive Care Plans for PASRR and Hospice Residents
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed all required areas for three residents. For two residents with Level II Pre-admission Screening Resident Review (PASRR) determinations, their care plans did not reflect their PASRR status in a timely manner. One resident's PASRR Level II status was not included in the care plan until several months after admission, despite documentation and staff interviews confirming the requirement. There was confusion among staff regarding responsibility for ensuring PASRR status was included in the care plan, with both the Social Worker and MDS Nurses indicating differing understandings of their roles. Another resident's Level II PASRR determination was not care planned due to the notification letter not being uploaded into the system, which staff acknowledged as the likely cause for the omission. Additionally, a resident who was accepted into hospice care did not have hospice services reflected in their care plan, even though hospice provider notes and the Minimum Data Set indicated the resident was receiving hospice care. Staff interviews confirmed that hospice care should have been included in the care plan, and the MDS Nurse responsible acknowledged the omission. The Director of Nursing and Administrator both stated their expectation that hospice care would be included in the care plan when initiated.