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Based on staff interview and record review, the Critical Access Hospital (CAH) failed to ensure medical records, to include assessments, were accurately documented for 1 of 9 applicable patients. (Patient #1) Findings include:

Per record review, Patient #1 was admitted to the CAH on 2/13/19 after experiencing generalized weakness and fever secondary to a chronic illness. Patient #1 was initially held in an Observation status (a short-term outpatient status used for monitoring of the patient). On 2/15/19 Patient #1 was admitted to a CAH Swing Bed (a Medicare program that allows a patient to receive nursing home skilled services in the hospital setting). Patient #1 was evaluated by Physical therapy and Occupational therapy to determine the patient's physical limitations and ability to provide self-care. It was determined Patient #1 would benefit from a longer rehabilitation program and discharge plans discussed potential transfer to an available bed in a skilled nursing facility (SNF). Eventually, a discharge plan became acceptable for Patient #1 and s/he was discharged to a local SNF for continued rehabilitation. A Federal requirement mandates a PASRR (Pre-Admission Screening and Resident Review) prior to Patient #1's admission to the SNF. PASRR preliminary screening helps to ensure that individuals are not inappropriately placed in a SNF, specifically those with a diagnosis with an intellectual or developmental disability without additional services to meet all their care needs. The Case Management department at the CAH was identified to be responsible for the completion of the PASRR prior to a patient's discharge to a SNF.

On 2/21/19 a RN/Case Manager completed an inaccurate PASRR screening for Patient #1. Under Part C - Intellectual Disability or Related Condition the RN/Case Manager answered "yes" to question #4: "Is there presenting evidence (cognition or behavioral) that indicated this individual may have an intellectual/developmental disability or related condition ?" The RN/Case Manager further documents per SLUMS (St. Louis University Mental Status Exam) the patient scored "25" and has "dementia". Per interview on 5/29/19 at 10:35 AM, a Occupational Therapist (OT) who evaluated/assessed Patient #1's physical abilities/self care deficits stated a SLUMS test was never performed on Patient #1, which is generally the responsibility of the therapies department to conduct. The therapist also noted a score of "25" was also inaccurate when rating an individual for dementia. In further review of Patient #1's medical record "dementia" was not identified as an issue or diagnosis. The inaccurate PASRR screening was sent to the Department of Mental Health as required and also to the receiving SNF. Per interview on 5/28/19 at 8:15 AM, Patient #1 stated s/he was upset the PASRR identified her/him to have dementia and this inaccurate information was reported directly to the SNF.

Per interview on 5/29/19 at 2:00 PM, the Director of Population Health & Care Management confirmed s/he does not routinely review completed PASRR screenings and identified there were opportunities for improvement with the RN/Case Manager's understanding of various patient screenings and assessments and reinforcing the accuracy of the medical record.