Failure to Accurately Complete PASRR Assessments for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments accurately reflected the mental health diagnoses of two residents. For one resident, the admission Minimum Data Set (MDS) indicated severe cognitive impairment, a diagnosis of depression, and symptoms of delirium, with orders for both antipsychotic and antidepressant medications. However, the level 1 PASRR assessment did not identify any indicators of serious mental illness and did not trigger a level 2 PASRR referral, despite the resident's documented mental health conditions. Staff later acknowledged that the PASRR was inaccurately completed and should have included the resident's diagnoses, necessitating a level 2 referral. For another resident, the significant change MDS documented diagnoses of depression and anxiety disorder, but the level 1 PASRR assessment did not include these diagnoses. A subsequent level 2 PASRR assessment, which relied on the inaccurate level 1 PASRR, failed to identify the resident's underlying mental health conditions, resulting in an invalidated referral. Facility staff confirmed that the omission of these diagnoses in the PASRR assessments was an error and should have been identified and corrected.