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F0645
D

Inaccurate PASRR Completion for Resident with Mental Health Conditions

Downers Grove, Illinois Survey Completed on 04-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to its policy for completing an accurate PASRR (Preadmission Screening and Resident Review) for a newly admitted resident, identified as R19. The deficiency was identified during an interview and record review, revealing that the facility did not have a qualified healthcare professional complete the Level I PASRR for R19. The resident was admitted with diagnoses including major depressive disorder, anxiety disorder, and seizures, and was prescribed medications such as sertraline, olanzapine, and venlafaxine for mental health conditions. However, the PASRR completed by the Admissions Coordinator, V26, inaccurately reported that there were no mental health diagnoses or medications, which was contrary to the resident's medical records. V26, who holds an associate degree in medical coding and is not a nurse or social worker, was responsible for completing the Level I PASRR. She admitted to not including R19's mental health medications in the PASRR submission, following instructions from a previous admissions coordinator. The facility's policy requires that PASRR submissions be completed by qualified healthcare professionals, such as nurses or social workers, and that all relevant diagnoses and medications be accurately reported. The inaccurate submission led to a Level I outcome indicating no need for a Level II PASRR, despite the presence of serious mental health conditions.

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