Failure to Update PASRR Level II Referrals for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer residents with newly diagnosed mental disorders for a Level II Pre-Admission Screening and Resident Review (PASRR) as required. Clinical record reviews and staff interviews revealed that three residents with diagnoses such as Schizoaffective Disorder, Bipolar Type, Major Depressive Disorder, and Anxiety Disorder did not have updated PASRR Level II evaluations completed after these diagnoses were made. The original PASRR forms for these residents indicated negative screens for serious mental illness, and no further evaluation was deemed necessary at the time, despite subsequent diagnoses that should have triggered a Level II referral. Specifically, one resident was diagnosed with Schizoaffective Disorder, Bipolar Type, and Major Depressive Disorder after the initial PASRR screening, but the PASRR was not updated. Another resident had diagnoses of Schizoaffective Disorder, Anxiety Disorder, and Major Depressive Disorder entered after the initial negative PASRR screening, with no update or referral for Level II evaluation. A third resident was admitted with physical health conditions, but later received diagnoses of psychosis, major depressive disorder, and anxiety disorder, again without an updated PASRR. Staff interviews confirmed that the required updates and referrals were not completed as mandated.