Failure to Accurately Complete PASRR Screening for Resident with Mental Disorder and Developmental Delay
Penalty
Summary
A deficiency occurred when the facility failed to accurately complete the Pre-Admission Screening and Resident Review (PASRR) for a resident with a history of bipolar disorder and developmental delay. The resident's Level I PASRR did not reflect his diagnosis of bipolar disorder or his diagnosis of lack of expected normal psychological development in childhood. As a result, a Level II PASRR, which is required for further assessment and potential specialized services, was never completed. The resident's admission records and hospital discharge summary documented his developmental delay and bipolar disorder, but these were not fully captured in the PASRR process. Interviews with staff and the resident's responsible party revealed ongoing behavioral health concerns, including agitation, verbal aggression, medication refusal, paranoia, and social isolation. Staff noted that the resident had escalating behaviors, refused care, and had to be moved to a private room due to his interactions with others. The responsible party and staff expressed concerns about the resident's mental health and the lack of mental health interventions or therapies being provided. The PASRR Level I screening, completed by the MDS Coordinator, marked "no" for questions regarding regional center services and did not accurately reflect the resident's functional limitations or history of substantial disability prior to age 22. The MDS Coordinator acknowledged that the PASRR was not completed accurately and that she had not contacted the local regional center to verify information or refer the resident for services. The Social Services Director confirmed that the resident had a diagnosis of developmental delay at admission and that a referral to the regional center should have been made. Facility policies required PASRR screening for individuals with major mental illness or developmental disabilities, but these procedures were not followed, resulting in the resident not being assessed for or receiving potentially beneficial specialized services.