Failure to Obtain and Document PASARR Level II Evaluations
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening Resident Review (PASARR) Level II evaluation was obtained and maintained in the charts for two residents who screened positive for mental disorders or intellectual disabilities. For both residents, documentation showed that they had diagnoses such as anxiety, dementia, and depressive disorder, and were dependent on staff for activities of daily living. Their PASARR Level I screenings indicated the need for a Level II evaluation, but there was no evidence in the records that the required follow-up with the PASARR Level II office occurred, nor was there documentation of any contact or response from the PASARR office. Interviews with the MDS nurse and the Director of Nursing confirmed that the facility's process requires follow-up with the PASARR Level II office if no response is received within three days. However, in both cases, the facility did not document any follow-up actions or communications. The facility's policy states that staff should coordinate recommendations from the PASARR Level II determination with resident assessments and care planning, but this was not done for the two residents identified in the report.