Failure to Update PASRR After Significant Change in Resident's Mental Health Status
Penalty
Summary
The facility failed to submit a new Preadmission Screening and Resident Review (PASRR) to the state agency after a significant change in status for a resident. The resident was originally admitted with a negative Level I PASRR, indicating no mental illness such as schizophrenia or depression. However, subsequent medical records showed that the resident was later diagnosed with unspecified schizophrenia and depression, and was prescribed antidepressant medications for these conditions. Despite these new diagnoses, the PASRR on file was not updated or resubmitted to the state agency for review. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for reviewing and updating PASRRs when a resident's condition changes. The Administrator, Admissions Director, Director of Social Services, MDS Coordinator, and DON each provided differing accounts of who was responsible for submitting updated PASRR information. The MDS Coordinator confirmed that the addition of new psychiatric diagnoses should have triggered a new PASRR submission, but acknowledged that the facility had not designated anyone to review PASRRs for accuracy. The facility's policy required that a new PASRR be submitted if a possible serious mental disorder or intellectual disability arises after admission. Despite this policy, the resident's PASRR remained outdated, and staff failed to identify and act on the significant change in the resident's mental health status. The deficiency was identified through record review and staff interviews, which confirmed that the required process was not followed.