Inaccurate PASARR Documentation for Residents
Penalty
Summary
The facility failed to ensure the completion and accuracy of Level I Preadmission Screening and Resident Review (PASARR) documents for four out of five residents reviewed. Resident #49 was admitted with several diagnoses, including major depressive disorder, but the PASARR Level I Screen did not list any mental illness diagnoses. Similarly, Resident #79, who had multiple mental health diagnoses and was on psychotropic medications, also had a PASARR Level I Screen that did not reflect these conditions. The MDS Coordinator and the Director of Nursing (DON) acknowledged the omissions but indicated that the responsibility for updating the forms was unclear due to recent staff changes. Resident #23, admitted with diagnoses including schizophrenia disorder-bipolar type and PTSD, had a PASARR Level I Screen that did not include these diagnoses. The MDS Coordinator confirmed the oversight, and the Nursing Home Administrator (NHA) stated that the Assistant Director of Nursing (ADON) was responsible for PASARRs, but the ADON had recently resigned. Resident #34, admitted with similar mental health diagnoses, also had a PASARR Level I Screen that failed to list these conditions. The DON and MDS Coordinator both acknowledged the inaccuracies, and the NHA confirmed the ADON's responsibility for ensuring PASARR completion and accuracy. The facility's policy requires that each resident be screened for mental disorders or intellectual disabilities prior to admission. However, due to a lack of clear responsibility and recent staff transitions, the PASARR forms were not updated to reflect the residents' current diagnoses. This resulted in a failure to make necessary referrals for specialized services or alternative placements for residents with mental health conditions.