PASARR Documentation Omission for Mental Health Diagnosis
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that a resident's diagnosed mental health condition was accurately reflected on their PASARR documentation. Specifically, a review of the resident's physician orders showed that the resident was prescribed Aripiprazole 2 mg daily for bipolar disorder, with the diagnosis documented in the resident's past medical history and H&P. However, the PASARR completed for the resident did not list bipolar disorder as a diagnosis. Staff interviews confirmed that the diagnosis was present in the medical history and associated with a current medication order, but it was not included in the list of current diagnoses used to generate the PASARR, and staff were unable to explain the omission.