Failure to Refer Resident for Level II PASARR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for a Level II Pre-Admission Screening and Resident Review (PASARR) after the resident received new diagnoses of depression and bipolar disorder. According to facility policy, any resident with a newly evident or possible serious mental disorder is to be promptly referred to the state mental health authority for a Level II review. The resident in question was admitted with a history of hemiplegia and hemiparesis and later received diagnoses of depression and bipolar disorder, as documented in the medical record and Minimum Data Set (MDS), which also indicated moderate cognitive impairment. Despite these new mental health diagnoses, there was no evidence in the resident's medical record that a Level II PASARR was resubmitted as required. Interviews with the Assistant Director of Nursing (ADON), Social Services Director (SSD), and Director of Nursing (DON) confirmed that a new PASARR should have been completed and submitted when the new diagnoses were added. The facility's leadership staff acknowledged responsibility for the PASARR process and stated that the expectation was for a new screening to be submitted following the addition of a new mental illness diagnosis.