Failure to Accurately Complete PASRR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident's Preadmission Screening and Resident Review (PASRR) was accurately completed. Medical record review showed that the resident was admitted with multiple diagnoses, including bipolar disorder, anxiety disorder, and major depressive disorder, and was receiving hospice services. The Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and required varying levels of staff assistance for daily activities. However, the PASRR documentation did not accurately reflect all of the resident's mental health diagnoses, as only mood disorder was marked, omitting the diagnoses of anxiety disorder and bipolar disorder. During an interview, the Director of Social Services confirmed that the PASRR was completed incorrectly and that the facility did not have a corrected PASRR on file for the resident. Review of the facility's PASRR policy confirmed the requirement for accurate completion and coordination with the state's PASRR program, including the need for a Level 1 screen upon admission and notification for a Level II screen if required. The deficiency was identified for one of two residents reviewed for PASRR, with a facility census of 72.