Failure to Accurately Complete PASRR for Resident
Summary
The facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASRR) for a resident, identified as Resident #166, out of five residents investigated for Level I PASRR. The deficiency was identified during a survey when it was found that the PASRR documentation for Resident #166 did not include any diagnosis, despite the resident having a history of mental illness. The PASRR screen decision-making section did not have any diagnosis checked, which was a significant oversight given the resident's medical history. The record review revealed that Resident #166 had an admission date with unspecified diagnoses. The Minimum Data Set (MDS) indicated that the resident was not considered by the state level II PASRR process to have a serious mental illness or intellectual disability, which was inconsistent with the resident's medication records and evaluation notes. The resident was taking medications that suggested a history of mental illness, yet this was not reflected in the PASRR documentation. Interviews with facility staff, including the Social Services Director and the Director of Care Coordination, revealed that there were discrepancies in the PASRR documentation. The Social Services Director acknowledged the discrepancies and noted that a resident review was scheduled to occur within 30 days of the evaluation to assess any changes in the patient's condition. The Director of Care Coordination stated that significant changes in a resident's condition are typically evident through behavioral changes, and the facility reviews PASRRs within 30 days for further evaluation. However, the failure to initiate a new resident review for Resident #166 earlier to include all mental illness diagnoses was a critical oversight.
Plan Of Correction
Immediate Action: The Pre Admission Screening and Resident Review for sample resident #166 was reviewed, updated, and submitted to the appropriate state agency on . Confirmation of update and receipt of determination has been obtained and was filed in residents chart. The staff member responsible received a 1:1 education on procedure for completing the Pre Admission Screening and Resident Review by Corporate Director of Social Service. Identification of Residents with potential to be affected: All residents have the potential to be affected. System Changes: The PASRR Policy was reviewed with all Social Work Staff responsible for completing PASRR Level I and requirement. All newly admitted residents will have the Pre Admission Screening and Resident Review reviewed for accuracy and resubmitted when inaccuracies are identified. Monitoring: A Pre Admission Screening and Resident Review audit for all admissions and present residents are being reviewed by the Social Work Director to ensure accurate completion. The Audit results will be submitted to the monthly Quality Assurance Performance Improvement Team for review. The audit will continue for 90 days or until the committee agrees substantial compliance is achieved. Responsible Party: Director of Social Work Corporate Director of Social Work/ Care Coordinator
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple medical conditions was newly diagnosed with schizophrenia and exhibited increased behaviors, but the facility did not complete an updated PASRR assessment or notify the state mental health agency as required. The DON confirmed the omission, which was not in accordance with facility policy.
The facility did not timely initiate or complete required PASRR screenings and hospice condition change submissions for several residents with mental disorders, intellectual disabilities, or significant cognitive impairments. PASRR documentation was missing or delayed for residents with diagnoses such as schizophrenia, dementia, and those receiving hospice care, as confirmed by staff interviews and record reviews.
A resident with multiple mental health diagnoses, including PTSD, was admitted without accurate completion of the PASARR screening. The PASARR form failed to document the PTSD diagnosis and did not list prescribed psychotropic medications, as confirmed by facility staff interviews.
A resident with documented PTSD and other diagnoses was admitted without their mental health conditions being accurately reflected on the PASARR screening form. The PASARR omitted relevant diagnoses despite these being present in the medical record and MDS assessment, and staff confirmed the form was not completed correctly.
The facility did not ensure that Level I PASARR forms accurately documented mental health diagnoses and psychotropic medication use for two residents. Both individuals had documented histories of mental disorders and were prescribed psychotropic medications, but their PASARR forms failed to reflect this information. Facility staff confirmed the inaccuracies and acknowledged lapses in the review process.
A resident admitted with a hospital exemption and a diagnosis of intellectual disability did not have a PASARR completed within 30 days as required. The resident's medical record and staff interview confirmed the absence of the PASARR, despite facility policy and hospital documentation indicating the need for timely completion.
Failure to Notify State Agency of Significant Change in Mental Health Condition
Penalty
Summary
The facility failed to notify the appropriate state agency, the Ohio Department of Mental Health, of a significant change in a resident's mental health condition as required by regulation. Record review showed that a resident was admitted with multiple diagnoses, including anxiety and epilepsy, and later received new diagnoses of disorganized schizophrenia and schizophrenia. Despite these new mental health diagnoses and an increase in behaviors, there was no evidence in the medical record that an updated PASRR assessment was completed or that the state agency was notified. Staff interviews confirmed that no updated PASRR was completed at the time of the new diagnoses, and the Director of Nursing acknowledged that a PASRR should have been conducted. Facility policy requires prompt referral to the state mental health authority for a level II resident review when a resident exhibits a newly evident or possible serious mental disorder. The failure to follow this policy and regulatory requirement resulted in the deficiency.
Failure to Timely Complete PASRR Screenings and Submissions
Penalty
Summary
The facility failed to timely initiate and complete Preadmission Screening and Resident Review (PASRR) processes for residents with mental disorders or intellectual disabilities. Specifically, four residents were affected by these deficiencies. One resident was admitted with diagnoses including schizophrenia, depressive disorder, and anxiety, but did not have a PASRR screen completed prior to admission; the Level I PASRR was not completed and signed until several months after admission, and a Level II PASRR was only initiated following a later diagnosis change. Three other residents, all of whom had significant cognitive impairments and were receiving hospice services, did not have required PASRR hospice condition change submissions and results documented in their records. Interviews with the Social Service Designee confirmed that PASRR screenings were either missing, incomplete, or not completed in a timely manner for these residents. The designee acknowledged that diagnosis changes, hospice status, and other significant condition changes should be submitted within a few days, and that newly admitted residents should have PASRRs completed prior to or within 30 days of admission. The findings were based on both record reviews and staff interviews, which verified the lack of timely and complete PASRR documentation for the affected residents.
Incomplete PASARR Documentation for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) was completed accurately for one resident upon admission. Medical record review showed that the resident had multiple diagnoses, including acute and chronic respiratory failure, type 2 diabetes, bipolar disorder, depression, post-traumatic stress disorder (PTSD), adjustment disorder with depressed mood, and attention-deficit hyperactivity disorder. However, the PASARR form did not include the diagnosis of PTSD or identify the psychotropic medications prescribed to the resident. This omission was confirmed during interviews with the social worker and the regional director of social services and activities, both of whom verified that the PASARR was inaccurate and incomplete regarding the resident's PTSD diagnosis and psychotropic medication use.
Inaccurate PASARR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that the level one Preadmission Screening and Resident Review (PASARR) accurately reflected a resident's existing mental illness at the time of admission. Specifically, a resident admitted with diagnoses including dementia, post-traumatic stress disorder (PTSD), and epilepsy had a PASARR Identification Screen that did not indicate any of the resident's mental health diagnoses, despite PTSD being documented as an active diagnosis in the resident's Minimum Data Set (MDS) assessment. The PASARR form omitted relevant diagnoses such as mood disorder and other mental disorders, which were present in the resident's medical record. Staff interviews confirmed that the PASARR was not completed accurately and that there was no facility policy in place for PASARRs at the time.
Inaccurate PASARR Documentation for Mental Disorders and Psychotropic Medications
Penalty
Summary
The facility failed to ensure that Level I Preadmission Screening and Resident Review (PASARR) forms accurately reflected all diagnosed mental disorders and prescribed psychotropic medications for two residents. According to the facility's policy, all potential admissions must be screened individually to determine if they meet criteria for serious mental illness, intellectual disability, or related conditions. However, for two residents, the PASARR forms did not document existing mental health diagnoses or the use of psychotropic medications, despite clear evidence in their medical records and medication administration records. One resident was admitted with diagnoses of post-traumatic stress disorder, major depressive disorder, and a history of suicide attempt, and was prescribed multiple psychotropic medications including antipsychotics, antidepressants, and antianxiety agents. The PASARR form for this resident, completed by the Social Services Director, incorrectly indicated that the resident had not received any psychotropic medications in the past six months. Interviews with facility staff confirmed that the PASARR form was inaccurate and that there was uncertainty about who was responsible for reviewing the forms for accuracy. Another resident was admitted with a diagnosis of schizophrenia and was prescribed antipsychotic, antidepressant, and mood stabilizer medications. The PASARR form for this resident failed to indicate the presence of a mental disorder or the use of psychotropic medications, despite documentation in the resident's records. Facility staff, including the DON and Administrator, acknowledged that the PASARR forms were incomplete and did not accurately reflect the residents' conditions or medication use at the time of admission.
Failure to Complete PASARR Within Required Timeframe for Resident with Intellectual Disability
Penalty
Summary
A deficiency occurred when the facility failed to complete a Preadmission Screening and Resident Review (PASARR) within 30 days for a resident admitted with a hospital exemption. The resident was admitted with diagnoses including osteoarthritis, benign prostatic hyperplasia, chronic kidney disease stage three, and unspecified intellectual disabilities. The resident's intellectual disability, which manifested prior to age 22, was documented in both the hospital exemption and the facility's diagnosis list at the time of admission. The hospital exemption specifically indicated that the facility was responsible for electronically initiating a PASARR prior to the 30th day following admission. Despite these requirements, a review of the resident's medical record revealed that a completed PASARR was not present. The admission Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired and required staff assistance with activities of daily living. Staff interview confirmed that the PASARR had not been completed for the resident, and facility policy stated that the PASARR should be provided prior to or upon admission.
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