Failure to Accurately Complete PASRR for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to accurately complete and submit the Preadmission Screening and Resident Review (PASRR) for a resident who was admitted with multiple psychiatric diagnoses, including Unspecified Psychosis, Major Depressive Disorder, and Psychotic Disorder with Delusions. Upon admission, the resident was prescribed psychotropic medications such as citalopram, haloperidol, and trazodone. However, the PASRR intake form did not list any of these medications or psychiatric diagnoses, and questions regarding the resident's history of mental illness and use of psychotropic medications were incorrectly answered as 'No.' Only the admitting diagnosis of cerebral infarction was included on the form. Interviews with facility staff, including the Accounts Manager, DON, and Social Worker, confirmed that the PASRR was completed inaccurately. The Accounts Manager admitted to only listing the primary diagnosis and not being familiar with psychiatric diagnoses or psychotropic medications that should have been included. Both the DON and Social Worker verified that the resident was admitted with mental health diagnoses and on psychotropic medications, and agreed that the PASRR should have triggered a Level II evaluation. The deficiency was identified through review of the resident's records and staff interviews, which revealed the omission of critical information necessary for proper PASRR processing.