Failure to Complete Accurate PASARR Assessments for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that accurate and complete Preadmission Screening and Resident Review (PASARR) assessments were conducted for two residents. For one resident admitted with a diagnosis of bipolar disorder, the PASARR assessment incorrectly documented dementia and did not reflect the actual diagnosis of a serious mental illness. The resident's medical record confirmed the absence of dementia and the presence of bipolar disorder, but this was not accurately captured in the screening process. Staff interviews revealed that the admissions and nursing teams were responsible for verifying diagnoses and making appropriate Level II PASARR referrals, but this process was not properly followed. For another resident admitted with schizophrenia, the PASARR assessment did not document the presence of a serious mental illness or trigger a Level II referral, despite the resident's history and ongoing involvement with community mental health services. Progress notes indicated the resident's connection to mental health housing and treatment teams, yet the required screening and referral were not completed. Staff interviews confirmed that a diagnosis of schizophrenia should have prompted a Level II evaluation, but this step was missed.