Failure to Accurately Complete PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to accurately review and complete the annual Pre-Admission Screening Assessment and Resident Review (PASARR) for three of sixteen sampled residents. For one resident, the Level I PASRR screening was positive for serious mental illness, intellectual disability, developmental disability, or related condition, but no Level II PASRR was completed as required. The Director of Nursing (DON) confirmed that the Level I screening was positive and acknowledged that it was their responsibility to ensure the PASRR process was completed, but this did not occur. For two other residents, the PASRR Level I screenings were marked negative despite both residents having documented mental health diagnoses and being prescribed psychotropic medications. The admission records and order summaries indicated diagnoses such as unspecified psychosis, depression, and anxiety disorder, along with medications like Risperidone, Valium, and Lexapro. The DON acknowledged that the PASRR Level I screenings were not completed accurately, which resulted in the screenings not triggering the required Level II PASRR evaluations. The facility's policy stated that positive Level I screens should be referred for Level II evaluation, but this process was not followed.