Failure to Accurately Reflect Mental Health Diagnosis in PASARR Screening
Penalty
Summary
The facility failed to ensure that a Level I Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of a diagnosed mental illness for one resident. The resident was admitted with a diagnosis of generalized anxiety disorder, which was documented in the admission record as an active diagnosis and classified as an admission diagnosis. The resident's Minimum Data Set (MDS) assessment confirmed the presence of an active anxiety diagnosis and indicated the use of antipsychotic and antidepressant medications. However, the Level I PASARR completed at the hospital prior to admission did not reflect the resident's diagnosis of generalized anxiety disorder or the use of psychotropic medications, resulting in a negative PASARR and no Level II evaluation being required. Interviews with facility staff revealed that hospital staff typically completed the Level I PASARRs, and facility staff were expected to review them for accuracy upon admission. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the facility had recently started checking PASARRs for accuracy due to previous omissions by hospitals, but had not reviewed all prior admissions. In this case, no corrected Level I PASARR was completed upon the resident's admission, despite the presence of a qualifying mental health diagnosis.