Failure to Complete Required Level II PASRR Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with a diagnosed mental illness received a required Level II PASRR (Preadmission Screening and Resident Review) evaluation. The resident, who had a history of Alzheimer's disease, non-Alzheimer's dementia, anxiety, depression, and bipolar disorder, was admitted with a positive Level I PASRR screening indicating the need for a Level II evaluation. Despite this, documentation showed that the Level II PASRR was not completed, with correspondence from the Department of Health Care Services at one point stating the evaluation could not be conducted due to the resident being isolated for health or safety reasons, and later stating the resident did not require the screening due to not having a severe mental illness. The resident's cognitive status declined over time, as evidenced by a drop in BIMS score from 11 to 3, indicating severe cognitive impairment. Interviews with facility staff revealed a lack of clarity and policy regarding the PASRR process. The Business Manager was unaware of the steps to take if the acute care hospital did not complete the PASRR accurately or if a resident developed a mental illness while in the facility. The Administrator acknowledged that a Level II PASRR should have been conducted and identified a gap in the facility's PASRR process. The facility's policy required referral for Level II evaluation when indicated, but this was not followed, resulting in the resident not receiving a complete mental health evaluation or access to appropriate mental health resources.
Plan Of Correction
On 4/25/25, the Administrator completed a revision of the facility's policy and procedure (P&P) for PASSR to 1) include the definition of a significant change and 2) address what to do when a resident is noted to have a significant change of condition. On 4/28/25, the Administrator revised the P&P with the facility's current PASSR system, authorized users, and the Interdisciplinary Team (IDT), the requirement that a Resident Review (RR) must be initiated by submitting a Level I Screening upon a resident's significant change in condition. On 4/28/25, the Administrator reviewed with the Interdisciplinary Team (IDT) the definition of a "significant change of condition." The facility's current PASSR System authorized users include the Business Office Manager, Business Office Assistant, and Admission's Director. The IDT includes the Director of Nurses, Director of Staff Development, Minimum Data Set Nurse, Social Services Director, Activities Director, Rehabilitation Director, Medical Records Designee, and Administrator. The IDT will review changes of condition as defined in the P&P during morning stand-up meetings and communicate the need to submit Level I Screening to PASSR systems users as needed. The Medical Records Designee will audit changes of conditions and for completion of the process and report findings to the IDT. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.