Failure to Complete Accurate PASARR Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that individuals with mental disorders, intellectual disabilities, or related conditions had accurate Level I Preadmission Screening and Resident Reviews (PASARR) completed upon admission and updated as needed. For two residents, the Level I PASARR assessments did not include all relevant psychiatric diagnoses, such as anxiety, depression, and bipolar disorder, despite these conditions being documented in their medical records and reflected in their medication orders and care plans. In one case, a resident with multiple psychiatric diagnoses and behaviors was admitted with a PASARR that omitted these diagnoses, and the need for a Level II PASARR assessment was not determined. In another case, a resident with depressive episodes and anxiety was admitted with a PASARR that did not reflect her psychiatric conditions, even though her behaviors and medication use indicated active mental health concerns. Interviews with facility staff revealed that the process for reviewing and updating PASARR documentation was not consistently effective. The interdisciplinary team reviewed PASARRs within 24 hours of admission, and the MDS staff was responsible for quarterly reviews, but discrepancies in psychiatric diagnoses were not identified or addressed. The facility's policy required screening for mental and related disorders and referral for further assessment as needed, but this process was not followed in these cases, resulting in incomplete PASARR documentation and potential gaps in care planning.