Failure to Update PASRR Assessment After Significant Change in Resident Condition
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) assessments were completed for residents following a significant change in status or when newly evident or possible serious mental disorders were present. Specifically, one resident with a history of depression, psychotic disorder with delusions, and dementia was readmitted and subsequently prescribed both antidepressant and antipsychotic medications. However, the resident's most recent PASRR did not reflect the use of these medications, nor did it indicate a Level II recommendation, and no updated PASRR was found in the electronic health record. Interviews with facility staff revealed that the process for reviewing and updating PASRR assessments was not consistently followed, particularly in the absence of a social worker. Nursing staff described their roles in monitoring psychotropic medication use and obtaining consents, but there was a lack of clarity regarding responsibility for initiating a new PASRR when a resident began new psychotropic medications after admission. This lapse resulted in a potential delay in access to appropriate Level II PASRR services for the resident.