| 88 |
THE PILLARS OF BILOXI |
255093 |
2279 ATKINSON ROAD |
BILOXI |
MS |
39531 |
2019-05-15 |
644 |
D |
0 |
1 |
0E0S11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, and staff interview, the facility failed to provide a Level II Pre-Admission Screening and Resident Review (PASRR) for one (1) of three (3) sampled residents, Resident #21, reviewed for PASRR screenings. Specifically, Resident #21 was diagnosed with [REDACTED]. Findings include: Review of the facility policy, titled Physician Certification for Nursing Facility and MI/MR Screening, revised 09/05/14, revealed the purpose of the screening was for the physician to certify that a resident was appropriate for admission to a long-term care Medicare/Medicaid facility. Additionally, the policy revealed Social Services (S.S.), the Admissions Coordinator, and Medical Records (MR) personnel (or MR designee) would be responsible for completing and submitting the PASRR screening documents to the State Agency. Review of the Admission Record in Resident #21's electronic clinical record, revealed an original admission date of [DATE], and a readmission date of [DATE]. The Pre-Admission Screening (PAS) Level I Application for Long Term Care was completed on 05/16/17. According to the responses entered on the PAS application, Part B-Criteria for referral for Level II screening, the resident did not meet the criteria for a Level II screen. At that time there was no [DIAGNOSES REDACTED]. Continued review Resident #21's Admission Record, revealed a [DIAGNOSES REDACTED]. Review of Resident #21's admission Minimum Data Set (MDS) Assessment, dated 04/21/17, revealed in Section I: Active Diagnoses: [REDACTED]. Review of Psychiatric Notes, dated 06/14/17, and 07/05/17, revealed the resident was assessed with [REDACTED]. The resident reported to the Psychotherapist that he believed staff were talking about killing him. Review of a MDS Significant Change Assessment, dated 03/05/19, revealed Paranoid [MEDICAL CONDITION] was listed among Resident #21's diagnoses. Review of Resident #21's current Physician Orders, dated 05/15/19, revealed the resident had orders for [MEDICATION NAME] 1.5 milligram (mg) one (1) time per day, and for [MEDICATION NAME] 1.75 mg at bedtime. [MEDICATION NAME] is an antipsychotic medication used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorder. Review of Resident #21's Comprehensive Care Plan (CP), revealed the CP included the resident's [DIAGNOSES REDACTED]. In an interview, on 05/15/19 at 4:21 PM, with the Business Office Manager (BOM), she stated that she was responsible for completing the PASRR Level I screening for newly admitted residents. She said the PAS date of 05/16/17, was the date the application was submitted to the State Agency. The BOM said she usually asked the Minimum Data Set (MDS) Nurse to review newly admitted resident's medications and to let her know if the resident was taking [MEDICAL CONDITION] medications. She said she was required to answer a question on the form about the resident's use of [MEDICAL CONDITION]. The BOM said she typically did not ask a nurse or physician to review the resident's diagnoses, because when she transmitted the completed Pre-Admission Screening (PAS) Level I Application for Long Term Care, she also transmitted the resident's History and Physical, their Admission Face Sheet including diagnoses, and the physician's orders to the State Agency to review. She said the State Agency would review the information and would notify the facility if the resident needed a Level II screening. She said the State Agency would then send a representative to the facility to complete the Level II screening. The Business Office Manager stated in Resident #21's case, another PASRR application should have been submitted to the State Agency when the [DIAGNOSES REDACTED]. She said, as far was she knew, there was no system in place that would alert her that a resident received a new [DIAGNOSES REDACTED]. |
2020-09-01 |