Failure to Complete and Document PASRR Screenings for Residents with Mental Disorders or Intellectual Disabilities
Penalty
Summary
The facility failed to ensure that residents with mental disorders or intellectual disabilities were appropriately assessed through the Preadmission Screening and Resident Review (PASRR) process upon admission or as needed. Specifically, five residents with significant psychiatric or developmental diagnoses did not have complete or properly executed PASRR documentation. In several cases, residents were admitted under provisional or hospital discharge exemptions, but the required follow-up screenings were not conducted when the exemption period ended. For example, one resident was admitted under a 30-day provisional exemption but was not re-screened after the period expired, as confirmed by the Regional Nurse Consultant. Other residents had incomplete or unsigned PASRR Level I forms, or had sections of the form left blank despite having diagnoses and histories that clearly indicated the need for further assessment. In one case, a resident's PASRR Level I did not document any psychiatric diagnoses, even though the resident had a history of schizophrenia, depression, and anxiety, and was receiving multiple psychotropic medications. Another resident's PASRR Level I was not signed or dated by a physician, despite the presence of multiple psychiatric diagnoses and ongoing treatment with antipsychotic and anxiolytic medications. The facility's policy required that all residents with serious mental illness or intellectual disability receive appropriate preadmission screenings and that documentation be maintained in the medical record. The policy also specified that exemptions must be properly documented and that follow-up screenings be conducted as required. However, interviews with staff and review of records revealed that these procedures were not consistently followed, resulting in incomplete or missing PASRR documentation for residents with significant mental health needs.