Failure to Complete PASARR Level II Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of mental illness received a required PASARR Level II (PE) screening. The resident, a female with diagnoses including bipolar disorder and schizoaffective disorder, was admitted and later readmitted to the facility. Her records, including the face sheet, PASARR Level I screening, MDS assessment, and care plan, all indicated the presence of mental illness. Despite this, there was no evidence in the clinical record that a PASARR Level II evaluation had been completed for her. Interviews with the facility's MDS coordinator confirmed that the PASARR Level II assessment was not performed. The coordinator acknowledged responsibility for completing PASARR screenings and stated that she would have checked for the Level II assessment if she had been present during the resident's comprehensive assessment. The facility's policy requires that a PASARR be completed for all patients with mental illness, and a Level II assessment is specifically required for those with new mental health diagnoses upon readmission, but this process was not followed for the resident in question.