Failure to Update PASRR for Resident with New Diagnosis
Summary
The facility failed to submit a new Preadmission Screening and Resident Review (PASRR) assessment for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, schizophrenia, and depression. The resident's Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of 3, reflecting severe cognitive impairment. The resident's PASRR Level 1 Screening Outcome had previously referred them for a Level II onsite visit, but the PASRR determination excluded them from further PASRR requirements due to no PASRR diagnosis. However, a new diagnosis of paranoid schizophrenia was documented in the resident's medical records, which should have prompted a PASRR update. The Director of Nursing (DON) acknowledged awareness of the new diagnosis but failed to submit the required PASRR update. The facility's policy mandates that if a resident is diagnosed with a mental disorder while in the facility, the designated individual must contact the state agency for a Level II screening. The policy also requires that PASRR recommendations be incorporated into the care plan and that the state-designated mental health authority be notified promptly when a resident experiences a significant change in mental or physical status. Despite these requirements, the necessary PASRR update was not completed for the resident, leading to the deficiency.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple complex diagnoses was admitted without evidence of a completed PASARR screening, as required by facility policy. The PASARR was only provided after surveyors requested it, and staff interviews confirmed that the screening should have been done at admission.
A facility failed to accurately complete a PASARR for a resident with multiple mental health diagnoses, leading to the omission of a necessary level II evaluation. The admissions coordinator, lacking formal training, incorrectly assessed the resident's mental health status based on their ability to live independently, rather than documented diagnoses. This oversight was identified during a clinical record review, revealing a gap in the facility's implementation of its PASARR policy.
A resident with multiple mental health diagnoses was admitted to a facility without the staff incorporating the Level II PASARR recommendations into their care plan. The staff were unaware of the Level II PASARR until requested by surveyors, and the care plan lacked necessary information. The discharge planner incorrectly completed a Level I PASARR, stating no Level II evaluation was needed due to severe physical illness, despite the resident being alert and communicative.
Failure to Complete PASARR Screening on Admission
Penalty
Summary
Facility staff failed to ensure that a preadmission screening and resident review (PASARR) was completed for one resident upon admission. The resident, who was admitted with diagnoses including quadriplegia, neurogenic bowel/bladder, and delusional disorders, did not have evidence of a completed PASARR in the clinical record at the time of admission. The PASARR was only provided later, after the deficiency was identified during the survey. Review of the resident's records showed a comprehensive care plan addressing depression and a recent MDS assessment indicating no cognitive impairment, but there was no documentation of a PASARR prior to or at the time of admission. Staff interviews confirmed that social services are responsible for completing PASARRs on admission, and the facility's policy requires review and completion of PASARRs before admission. The deficiency was acknowledged by facility leadership when presented by surveyors.
Failure to Complete Accurate PASARR for Resident with Mental Illness
Penalty
Summary
The facility staff failed to accurately complete a pre-admission screening and resident review (PASARR) for a resident with multiple mental health diagnoses, including post-traumatic stress disorder, major depressive disorder, unspecified psychosis, paranoid schizophrenia, paranoid personality disorder, and unspecified schizophrenia. The level I PASARR, completed by an admissions coordinator, incorrectly marked that the resident did not have a current serious mental illness, which led to the omission of a necessary level II evaluation. The admissions coordinator, who had not received formal training on PASARR completion, based her decision on the resident's ability to live independently and manage daily activities, rather than the documented mental health diagnoses. The deficiency was identified during a clinical record review, which revealed that the resident's diagnoses were not considered in the PASARR assessment. The admissions coordinator acknowledged the oversight and admitted to not being aware of the resident's updated diagnoses. The facility's director of nursing confirmed the presence of these diagnoses in the clinical record, which were supported by past medical documentation and medication reports. The facility's policy on PASARR screenings emphasizes the importance of identifying individuals with mental illness to ensure appropriate care, but this policy was not effectively implemented in this case.
Failure to Incorporate Level II PASARR Recommendations
Penalty
Summary
The facility staff failed to obtain and incorporate the recommendations from a Level II PASARR into the assessment and care plan for a resident in the survey sample. The resident, who had a Level II PASARR, was admitted to the facility with multiple diagnoses, including hemiplegia, schizoaffective disorder, and major depressive disorder. Despite these conditions, the facility staff were unaware of the Level II PASARR until it was requested by the survey team. The care plan did not address the Level II PASARR or its recommendations, and the facility's documentation did not include the necessary information. During the survey, it was discovered that the discharge planner/social services director had completed a Level I PASARR, which incorrectly indicated that no Level II evaluation was required due to a severe physical illness. However, the resident was alert and communicative, contradicting the justification for not performing a Level II PASARR. The facility's policy required that any Level II PASARR be incorporated into the care plan within five days of admission, but this was not done. The facility administrator was informed of these findings during an end-of-day meeting.
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