Failure to Complete PASRR Level Two After New Schizoaffective Disorder Diagnosis
Penalty
Summary
The facility failed to complete a new Pre-Admission Screening and Resident Review (PASRR) level two evaluation for a resident after a new diagnosis of Schizoaffective disorder was added. The resident was initially admitted with multiple medical conditions, including muscle weakness, hypothyroidism, protein-calorie malnutrition, encephalopathy, cellulitis, hypokalemia, hypertension, and cognitive communication deficit. The initial PASRR level one screening indicated no serious mental illness and no recent use of psychotropic medications. However, subsequent hospital records documented unspecified psychosis, adjustment disorder, refusal of medical treatment, and a determination of incompetence to make informed healthcare decisions. Following admission, the resident received several new orders for antipsychotic medications, and a new diagnosis of Schizoaffective disorder was formally added. Despite these significant changes in the resident's mental health status and treatment, the facility did not complete a new PASRR evaluation as required. This was confirmed during an interview with the Admissions Coordinator, who acknowledged that a significant change PASRR should have been completed for the resident.