Failure to Include Psychiatric Diagnoses in PASARR Screening
Penalty
Summary
The facility failed to ensure that a resident's psychiatric diagnoses were accurately included in the pre-admission screening, specifically the PASARR (Pre-Admission Screening and Resident Review) process. This deficiency affected one resident, identified as R109, who had documented diagnoses of schizoaffective disorder and schizophrenia. Despite these diagnoses being present in the resident's medical records and active medication orders, they were not included in the PASARR Level I screening. As a result, the initial determination incorrectly indicated that no Level II screening was required, which could have impacted the assessment of the resident's needs. The error occurred because the receptionist/office manager, who was responsible for completing the PASARR, did not include the necessary psychiatric diagnoses. The associate administrator acknowledged that the receptionist/office manager, being non-clinical, should have been guided by the nursing and social service departments regarding the resident's diagnoses and medications. This oversight was later corrected when a subsequent PASARR Level I screen identified the need for a Level II evaluation, citing the resident's mental health disabilities, including schizophrenia and schizoaffective disorder.