Incomplete PASARR Documentation for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) was completed accurately for one resident upon admission. Medical record review showed that the resident had multiple diagnoses, including acute and chronic respiratory failure, type 2 diabetes, bipolar disorder, depression, post-traumatic stress disorder (PTSD), adjustment disorder with depressed mood, and attention-deficit hyperactivity disorder. However, the PASARR form did not include the diagnosis of PTSD or identify the psychotropic medications prescribed to the resident. This omission was confirmed during interviews with the social worker and the regional director of social services and activities, both of whom verified that the PASARR was inaccurate and incomplete regarding the resident's PTSD diagnosis and psychotropic medication use.