Failure to Conduct Accurate PASRR Screenings
Penalty
Summary
The facility failed to obtain an accurate Pre-Admission Screening and Resident Review (PASRR) for a resident prior to their re-admission. The resident was initially admitted and later readmitted without any mental health diagnoses recorded. However, the resident's medication administration record indicated the use of psychotropic medication for anxiety, and the care plan noted a risk for adverse reactions related to psychotropic medication use. An updated Level I PASRR later revealed diagnoses of anxiety disorder, depressive disorder, adjustment disorder, and a history of PTSD, but still concluded that a Level II PASRR was not required. Additionally, the facility did not ensure that residents with mental illness or suspected mental illness were referred for Level II screening. One resident had a Level I PASRR that did not indicate a need for Level II screening despite having a diagnosis of PTSD and experiencing related symptoms such as nightmares and anxiety. The Director of Nursing stated that the resident did not qualify for a Level II PASRR because they were stable and did not exhibit behaviors. Another resident's Level I PASRR indicated anxiety disorder but did not check depressive disorder, despite the resident having diagnoses of anxiety, major depressive disorder, and adjustment disorder. The Director of Nursing stated that a Level II screen was not needed because the resident's dementia diagnosis was not primary or secondary. The facility's policy requires notification to the state mental health authority for significant changes in residents with mental disorders, but this was not adhered to in these cases.
Plan Of Correction
1. Resident #98's PASRR has been updated to accurately reflect the physical and mental condition of the resident. Resident #15 has been discharged from the facility. Resident #96 has been referred for a Level II PASRR. 2. Director Of Nursing/Social Services Director/Designee have completed a review of current facility residents to verify PASRR accurately reflects the resident and has been submitted for a Level II review if indicated. Follow up based on findings. 3. Staff Development Coordinator/Designee has provided education for Inter Disciplinary Team related to PASRR requirements. 4. Director Of Nursing/Social Services Director/Designee to complete monitoring of admission and readmission residents using the morning meeting process to verify PASRR accuracy and has been referred for a Level II if applicable for a period of 3 months, then quarterly as needed or until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.