Failure to Accurately Complete PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a required Level 1 Preadmission Screening and Resident Review (PASARR) was completed accurately for one resident. The resident was admitted with multiple mental health diagnoses, including depressive disorder, bipolar disorder, anxiety disorder, and mood affective disorder. The resident's history and physical indicated a lack of capacity to understand and make decisions, and the Minimum Data Set (MDS) assessment showed moderate cognitive impairment and significant assistance required for daily activities. The resident was also prescribed high-risk medications such as antipsychotics and antidepressants. Despite these documented mental health conditions, the PASARR Level 1 screening for the resident was marked as negative, indicating no serious mental illness and that a Level 2 screening was not required. The screening form specifically noted the absence of serious diagnosed mental disorders, which contradicted the resident's medical record and diagnoses. This inaccurate completion of the PASARR Level 1 screening prevented the initiation of a Level 2 PASARR evaluation, which is necessary for residents with serious mental illness to determine appropriate care and services. Interviews with facility staff, including Medical Records and the DON, confirmed that the PASARR process is intended to identify residents who require specialized mental health services prior to admission. Staff acknowledged that the Level 1 PASARR was not completed accurately for this resident and that a new screening should have been conducted. The facility's policy requires coordination with the PASARR program to ensure proper screening and referral for residents with mental disorders, but this process was not followed in this case.