Failure to Refer for PASRR Level II Evaluation After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for a Level II PASRR (Preadmission Screening and Resident Review) evaluation after new mental health diagnoses were identified. The resident, a female with a history of hemiplegia and hemiparesis following a cerebral infarction, was admitted with no documented mental illness at the time of her initial PASRR Level I screening. However, subsequent medical records showed new diagnoses of bipolar disorder and anxiety disorder, and the resident was prescribed antipsychotic medication for bipolar disorder with psychotic features. Despite these new diagnoses, the facility did not initiate a referral for a Level II PASRR evaluation as required. The social worker responsible for the initial PASRR Level I screening stated that she was unaware of the need for further evaluation and had not received formal PASRR training at the time. The MDS Coordinator also indicated a lack of familiarity with the PASRR process, including when to use specific forms, and had not received formal PASRR training during her tenure. Both staff members were unaware of the updated mental health diagnoses and did not complete the necessary documentation or referrals. Interviews with facility leadership revealed that there was no clear oversight or training structure in place to ensure staff responsible for PASRR were adequately trained or aware of their responsibilities. The Director of Nursing and Administrator were not aware of the changes in the resident's diagnoses or the requirements for PASRR referrals following new mental health findings. Facility policy required PASRR Level I completion prior to admission and Level II evaluation for residents with mental illness, but this was not followed in the case of the resident with new psychiatric diagnoses.