Failure to Initiate Level II PASRR for Resident with New Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with newly identified or possible serious mental disorders was properly reviewed for a Level II Pre-Admission Screening and Resident Review (PASRR). Record review showed that the resident was admitted with a PASRR Level I from the hospital indicating depressive disorder and no need for Level II screening. However, subsequent documentation at the facility included additional diagnoses of anxiety disorder, psychosis, and brief psychotic disorder. The resident's admission summary also noted a history of depression, dementia, and other medical conditions, and a psychiatry referral was made for evaluation and treatment of depression, anxiety, dementia, and psychosis. Despite these new or newly evident psychiatric diagnoses, the facility did not update the Level I PASRR to reflect the changes or initiate a Level II PASRR screening as required. The Director of Nursing confirmed that there was no documentation indicating that the PASRR had been revised or that a Level II screening had been started. Facility policy requires prompt referral for Level II review when a resident exhibits behavioral, psychiatric, or mood-related symptoms suggesting a mental disorder, but this process was not followed in this case.