Failure to Complete PASRR Level II Evaluations for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that two sampled residents with mental health diagnoses were referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required. One resident was admitted with diagnoses including bipolar disorder, major depressive disorder, and anxiety, and their medical record and care plan documented ongoing psychiatric and mood disorders. Despite these diagnoses, there was no evidence in the electronic medical record of a completed PASRR Level II evaluation, and the Director of Health Services confirmed that this had not been done and could not provide an explanation for the omission. Another resident was documented as receiving antipsychotic, antianxiety, and antidepressant medications, with care plan problem areas including behavioral symptoms, psychotropic drug use, elopement risk, and cognitive loss/dementia. This resident's diagnoses included schizoaffective disorder and bipolar disorder, yet there was also no PASRR Level II evaluation present in the medical record. The Social Worker confirmed that, based on the resident's diagnoses, a PASRR Level II should have been submitted but was not.