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F0645
D

Failure to Ensure Accurate PASARR Screening for Resident with Mental Health Diagnoses

Wenatchee, Washington Survey Completed on 05-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASARR) process for a resident with multiple mental health diagnoses. According to facility policy, the admission coordinator or designee is required to request and review a PASARR Level I screening prior to admission, with Social Services responsible for verifying its accuracy. For one resident, the PASARR Level I form indicated no serious mental illness indicators and did not trigger a Level II evaluation, despite the resident having documented diagnoses of dementia, delirium, hallucinations, anxiety, and depressive disorder. The comprehensive assessment also showed the resident had severely impaired cognition, required substantial assistance with activities of daily living, and was receiving hospice services. During interviews, the Social Services Director acknowledged responsibility for reviewing the PASARR form and admitted the form was filled out incorrectly, stating it should have been referred for a Level II evaluation prior to admission. The Administrator confirmed that both the admissions coordinator and Social Services Director were responsible for reviewing the PASARR forms and was unsure how the error was missed. The deficiency was identified through observation, interview, and record review, and was cited under WAC 388-97-1915(1)(2)(a-c).

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