Failure to Complete Accurate PASRR Assessment for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was completed for one resident who was reviewed for unnecessary medications. The resident was admitted with diagnoses including major depressive disorder and other mental health conditions. The Level I PASRR for this resident listed certain mental illnesses but omitted others, despite documentation in the hospital discharge summary and the Minimum Data Set (MDS) assessment indicating additional relevant diagnoses. The facility's policy requires that all individuals being admitted have a completed PASRR Level I prior to admission, and that the PASRR be reviewed for accuracy and corrected if necessary. During an interview, the Administrator acknowledged that the facility did not follow its process to review and correct the PASRR upon the resident's admission from the hospital. The resident's medical records, including a visit note and hospital discharge summary, documented a history of multiple mental health conditions that were not fully reflected in the PASRR. This failure to ensure an accurate PASRR assessment resulted in noncompliance with federal requirements for preadmission screening for individuals with mental illness or intellectual disability.