Failure to Complete PASRR Screening and Develop Care Plans for Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level I assessment for a resident upon readmission, despite the resident having new diagnoses of dementia, anxiety disorder, and Alzheimer's disease. The facility also did not promptly notify the mental health agency after these diagnoses were made, nor did it develop care plans addressing the resident's dementia, anxiety disorder, or Alzheimer's disease. These actions were identified through interviews and record reviews, which showed that the PASRR Level I screening was not completed as required by facility policy, and that there was confusion among staff regarding responsibility for completing the PASRR process. The resident in question had a history of Alzheimer's disease, unspecified dementia, major depressive disorder, and anxiety disorder, and was noted to have severely impaired cognition and lacked capacity to make decisions. Despite these significant mental health diagnoses and cognitive impairments, the facility's documentation did not reflect the completion of required assessments or the development of care plans tailored to the resident's needs. Interviews with the MDS Coordinator, MDSC Assistant, and DON confirmed that the PASRR Level I was not completed and that care plans for the new diagnoses were not created.