Failure to Accurately Complete PASRR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Level I Preadmission Screening and Resident Review (PASRR) for one resident. Upon admission, the resident had documented diagnoses of schizophrenia, psychosis, and anxiety disorder, and was prescribed multiple psychotropic medications, including Ativan and Chlordiazepoxide. The nursing admission assessment noted the resident was disoriented and had communication difficulties. However, the Level I PASRR completed did not reflect the resident's serious mental illness diagnoses or the use of psychotropic medications. As a result, the Notice of PASRR Level I Screening Results indicated that a Level II Mental Health Evaluation was not required, based on the inaccurate information provided in the Level I PASRR. During an interview and record review, the DON confirmed that the resident's diagnoses and medication orders were not included in the PASRR, acknowledging that this inaccuracy could affect the resident's access to necessary behavioral health services. Facility policies reviewed indicated requirements for individualized care planning and behavioral health services, including accurate PASRR screening and ongoing monitoring.