Failure to Reassess and Refer Resident for PASARR Level II Evaluation
Penalty
Summary
The facility failed to complete and re-submit the Preadmission Screening and Resident Review (PASARR) Level I screening and refer a resident with diagnoses of anxiety disorder and major depressive disorder (MDD) for a Level II evaluation, as required. The resident was initially admitted and later readmitted to the facility, with medical records indicating diagnoses of MDD, anxiety disorder, and congestive heart failure. The resident was assessed as having the capacity to make decisions and was independent in cognitive skills for daily decision making. Orders were placed for psychotropic medications, including Buspirone for anxiety and Sertraline for depression. Despite these diagnoses and the use of psychotropic medications, the facility relied on a previous PASARR Level I screening from another facility, which did not identify serious mental illness or psychotropic medication use at that time. The Minimum Data Set Nurse acknowledged that a new PASARR Level I screening should have been completed and resubmitted due to the resident's current mental health diagnoses and medication regimen. Facility policy and the PASRR reference manual both require referral for Level II evaluation when there is a new or significant change in mental health status, which was not done in this case.