Failure to Complete Required PASRR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that three out of six residents reviewed for Pre-Admission Screening and Resident Review (PASRR) received the required screenings for mental disorders or intellectual disabilities. For one resident with anxiety disorder, major depressive disorder, and PTSD, the initial PASRR Level I was completed as an exempted hospital discharge for a stay under 30 days, but no further PASRR evaluations were conducted after the resident remained in the facility beyond the exemption period. Another resident with anxiety disorder and depression had a Level I PASRR that did not document all relevant diagnoses, resulting in the absence of a required Level II evaluation. A third long-term resident with severe cognitive impairment, delusions, and a diagnosis of bipolar dementia had multiple Level I PASRRs indicating the need for a Level II referral, but no Level II PASRR was ever completed. Interviews with facility staff confirmed that PASRR evaluations were either not completed, not updated, or not accurately documented for these residents. Staff acknowledged awareness of the deficiencies, including missed referrals and inaccurate documentation, and indicated that they were responsible for reviewing PASRRs for accuracy. The facility's policy requires accurate and timely PASRR screenings and referrals, but these were not consistently followed, resulting in the identified deficiencies.