Failure to Update PASRR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident for a level II Pre-Admission Screening and Resident Review (PASRR) after the resident received a new diagnosis of major depressive disorder. The resident was originally admitted with diagnoses of generalized anxiety disorder and post-traumatic stress disorder, and the initial PASRR did not include major depressive disorder. When the new diagnosis was made, there was no evidence in the medical record that a level II PASRR was resubmitted to the appropriate state-designated authority. Interviews with facility staff, including the Admissions Director, MDS Coordinator, and DON, confirmed that the process for updating PASRR screenings after a new mental health diagnosis was not followed. Staff acknowledged that the new diagnosis should have triggered another PASRR screening to ensure the resident's information was accurate and to determine if a level II screening was necessary. The facility policy required screening for mental disorders prior to admission and evaluation for care in the most appropriate setting, but this was not adhered to in this case.