Failure to Complete Accurate PASRR Mental Health Screening
Penalty
Summary
The facility failed to accurately complete a mental health screening for one resident who was admitted with a diagnosis of bipolar disorder. According to the admission record, the resident's Preadmission Screening and Resident Review (PASRR) Level 1 screening was completed and indicated a negative result, not triggering a Level 2 mental health evaluation, despite the presence of a qualifying mental health diagnosis. The PASRR documentation also instructed the facility to resubmit a new Level 1 screening within 31 days, which was not done. Interviews with the Minimum Data Set Nurse (MDSN) and the Director of Nursing (DON) confirmed that the PASRR was inaccurate and should have led to a Level 2 evaluation, and that a new screening should have been completed within the required timeframe. The facility's policy also states that individuals meeting certain criteria should be referred for a Level 2 PASRR evaluation, which did not occur in this case.