Failure to Coordinate PASARR Level II Evaluations for Residents with Mental Health Needs
Penalty
Summary
The facility failed to coordinate the Preadmission Screen and Resident Review (PASARR) Level II services for two residents who required further evaluation for mental health needs. For one resident with moderate cognitive impairment, the Level I PASARR indicated a Level II evaluation was required, but no assessment was ever requested or obtained. This resident later developed new delusions and hallucinations and was started on new psychotropic medications, yet the PASARR was not updated to reflect these changes or to initiate a Level II referral. Another resident, admitted with a diagnosis of Post-Traumatic Stress Disorder and exhibiting symptoms such as mood instability, agitation, and refusals of care, also had a Level I PASARR indicating the need for a Level II evaluation. However, the assessment was never requested or obtained, despite the resident being treated with multiple psychotropic medications. Interviews with facility staff confirmed that the required referrals and documentation for Level II PASARR evaluations were not found in the electronic health record for either resident.